Lucchetta L, Mastroeni G, Rinonapoli G, Caraffa A, Gill SS, Pace V. Advancements in the diagnosis and management of complex trimalleolar ankle fractures: A comprehensive review. World J Orthop 2026; 17(1): 108554 [DOI: 10.5312/wjo.v17.i1.108554]
Corresponding Author of This Article
Valerio Pace, Department of Trauma and Orthopaedics, “Media Valle del Tevere - Pantalla” Hospital, Via del Buda, Pantalla 06059, Italy. valeriopace@doctors.org.uk
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Orthopedics
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Review
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Jan 18, 2026 (publication date) through Jan 9, 2026
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World Journal of Orthopedics
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2218-5836
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Lucchetta L, Mastroeni G, Rinonapoli G, Caraffa A, Gill SS, Pace V. Advancements in the diagnosis and management of complex trimalleolar ankle fractures: A comprehensive review. World J Orthop 2026; 17(1): 108554 [DOI: 10.5312/wjo.v17.i1.108554]
World J Orthop. Jan 18, 2026; 17(1): 108554 Published online Jan 18, 2026. doi: 10.5312/wjo.v17.i1.108554
Advancements in the diagnosis and management of complex trimalleolar ankle fractures: A comprehensive review
Lorenzo Lucchetta, Giampiero Mastroeni, Giuseppe Rinonapoli, Auro Caraffa, Saran Singh Gill, Valerio Pace
Lorenzo Lucchetta, Giampiero Mastroeni, Giuseppe Rinonapoli, Auro Caraffa, Department of Trauma and Orthopaedics, University of Perugia, Perugia 06100, Italy
Saran Singh Gill, Faculty of Medicine, Imperial College London, London SW72AZ, United Kingdom
Valerio Pace, Department of Trauma and Orthopaedics, “Media Valle del Tevere - Pantalla” Hospital, Pantalla 06059, Italy
Author contributions: Lucchetta L, Mastroeni G, and Gill SS designed the article; Lucchetta L, Mastroeni G, Rinonapoli G, Caraffa A, Gill SS, and Pace V performed the research and literature review, analyzed data, wrote and finalized the review; Gill SS finalized the review and undertook a review of the article; and all authors thoroughly reviewed and endorsed the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Valerio Pace, Department of Trauma and Orthopaedics, “Media Valle del Tevere - Pantalla” Hospital, Via del Buda, Pantalla 06059, Italy. valeriopace@doctors.org.uk
Received: April 17, 2025 Revised: July 16, 2025 Accepted: November 10, 2025 Published online: January 18, 2026 Processing time: 267 Days and 13.9 Hours
Abstract
Complex trimalleolar ankle fractures are a major orthopaedic challenge, with an incidence of 4.22 per 10000 person-years in the United States and an annual cost of 3.4 billion dollars. This review synthesizes current evidence on diagnostic protocols and management strategies, highlighting optimal approaches and emerging trends. Initial care emphasizes soft tissue assessment, often guided by the Tscherne classification, and fracture classification systems. External fixation may be required in open injuries, while early open reduction and internal fixation within six days is linked to improved outcomes. Minimally invasive techniques for the lateral malleolus, including intramedullary nailing and locking plates, are effective, while medial malleolus fractures are commonly managed with screw fixation or tension-band wiring. Posterior malleolus fragments involving more than 25% of the articular surface usually warrant fixation. Alternatives to syndesmotic screws, such as cortical buttons or high-strength sutures, reduce the need for secondary procedures. Arthroscopic-assisted open reduction and internal fixation benefits younger, active patients by enabling concurrent management of intra-articular and ligamentous injuries. Postoperative care prioritizes early weight-bearing and validated functional scores. Despite advances, complications remain common, and further research is needed to refine surgical strategies and improve outcomes.
Core Tip: The management of trimalleolar ankle fractures is often complex, with high incidence rates and substantial economic impact. Advanced imaging techniques, particularly computer tomography, have improved fracture assessment, influencing surgical planning and outcomes. Surgery management remains the gold standard, with timing and techniques being crucial to minimize complications and costs.
