Positioning strategies in surgical management of trimalleolar ankle fractures| Lo Scalpello - Journal

Abstract

Objective. Trimalleolar ankle fractures are complex injuries typically managed via open reduction and internal fixation (ORIF). While prone positioning is traditional for posterior malleolus access, floppy lateral positioning may improve the workflow for combined approaches. This study compared perioperative and radiographic outcomes between these two techniques.

Methods. A retrospective cohort study of 87 adult patients (prone: n = 45; floppy lateral: n = 42) was conducted at a Level I trauma center (2020-2024). Outcomes included operative time, fluoroscopic exposure, reduction quality, and postoperative complications.

Results. No significant differences were found in mean operative time (111.9 vs. 108.6 minutes; p = 0.235) or fluoroscopic exposure (39.0 vs. 38.4 seconds; p = 0.761). Both groups achieved high rates of anatomical reduction (92.77% vs. 92.42%; p = 0.561) with comparable complication rates and clinical outcomes.

Conclusion. Floppy lateral positioning provides equivalent surgical efficiency and radiographic outcomes to prone positioning. The choice of position can be safely guided by surgeon preference and patient-specific safety considerations.

Introduction

Ankle fractures represent approximately 10% of all skeletal injuries, with an annual incidence ranging from 100-250 cases per 100,000 people ¹. Trimalleolar fractures constitute one of the most challenging presentations of orthopedic trauma, accounting for approximately 15-20% of all unstable ankle injuries ². These injuries can cause severe complications due to difficulties in restoring the articular surface. These patients also sustain worse functional outcomes at longer follow-up intervals than those with bimalleolar fractures.

The anatomical complexity inherent to trimalleolar fractures necessitates meticulous surgical planning and precise reduction techniques to optimize joint surface restoration. Open reduction and internal fixation (ORIF) remain the standard surgical approach for unstable configurations, enabling direct visualization of fracture fragments and achieving anatomically accurate reduction ³. Over the past two decades, the surgical management of trimalleolar fractures has evolved, with a greater focus on joint stability and the role of posterior malleolar fragments in syndesmotic stability. Thus, more attention has been given to posterior fragment direct fixation ⁴.

Traditionally, timalleolar fractures are prone to be treated via the posterolateral approach and the medial approach. This positioning provides excellent visualization of posterior fragments and facilitates fibular plate fixation through the same approach ⁵. However, the prone position itself carries inherent risks that warrant consideration. Prolonged maintenance of the prone position has been associated with multiple serious complications, including brachial plexus injuries, postoperative visual loss secondary to ischemic optic neuropathy, and various pressure-related injuries ⁶. Furthermore, the prone position creates some issues for simultaneous access to medial ankle structures, often necessitating intraoperative repositioning or hybrid approaches that extend the operative time and anesthesia exposure ⁷.

Floppy lateral positioning represents a modified positioning strategy that places patients in a lateral recumbent orientation – typically described as the modified left lateral position or semiprone position – and has gained increasing attention as a potential alternative for ankle fracture surgery. This positioning strategy could reduce complications associated with the prone position and provide simultaneous access to posterior and medial ankle fractures without intraoperative repositioning ⁸.

Despite their theoretical advantages, comparative outcome data examining recovery positioning versus traditional prone positioning in trimalleolar fracture management remain limited in the contemporary literature.

The aim of this study was to compare the clinical, radiographic, and functional outcomes following ORIF for trimalleolar ankle fractures performed in the floppy lateral position and prone position via the posterolateral and medial approaches for fracture reduction and fixation. We hypothesized that the floppy lateral position would yield clinically equivalent outcomes while potentially reducing complications associated with prolonged prone positioning.

Materials and methods

Study Design and Patient Selection

This retrospective cohort study was conducted at a Level I trauma center. Patients were identified through trauma registry database screening and operative record review encompassing a 4-year period from 2020-2024. The inclusion criteria were as follows: (1) age ≥18 years; (2) diagnosis of trimalleolar ankle fracture (involving the medial, lateral, and posterior malleoli); (3) underwent treatment with operative fixation via posterolateral and medial approaches; and (4) minimum of 6 months of clinical and radiographic follow-up. The exclusion criteria were as follows: (1) open fractures requiring initial external fixation management; (2) trimalleolar fractures requiring the posteromedial approach; (3) pathological fractures or metabolic bone disease affecting surgical planning; (4) prior ankle surgery on the affected limb; (5) ipsilateral lower extremity injuries compromising analysis; and (5) incomplete medical record documentation.

Positioning Strategy and Surgical Technique

Patients were categorized into two groups on the basis of the intraoperative position selected by the attending surgeon: Group 1 (floppy lateral position, n = 45) and Group 2 (prone position, n = 42). Floppy lateral positioning involves placing the patient in modified lateral recumbency with the affected ankle dependent and the superior hip elevated to approximately 30°, facilitating simultaneous posterolateral and medial exposure. Prone positioning consisted of standard prone positioning on a surgical table with appropriate padding and support to prevent direct facial compression.

All procedures utilized the posterolateral approach for posterior malleolar visualization and fixation combined with standard medial malleolar exposure. Fracture fixation involves a combination of plates and screws on the basis of individual fracture morphology and surgeon preference. Syndesmotic stability was assessed intraoperatively via clinical stability testing and fluoroscopic evaluation, with syndesmotic fixation applied selectively on the basis of residual instability patterns.

Data collection

The demographic variables included patient age, sex distribution, body mass index, comorbidity burden, tobacco use status, and mechanism of injury. All patients underwent preoperative CT scans to assess fracture classification via both the Lauge-Hansen system and the AO/OTA system, posterior malleolar morphology according to the Bartonicek classification, and the presence of syndesmotic injury. The perioperative parameters recorded included the operative duration from skin incision to closure, anaesthesia exposure time, intraoperative blood loss, fluoroscopic image acquisition frequency, and requirement for intraoperative repositioning.

The postoperative assessment included a radiographic evaluation of the degree of anatomical reduction. Clinical outcomes were evaluated through documentation of deambulation status, time to independent weight-bearing, and analgesic requirements. Complication documentation included wound-related events (erythema, delayed healing, dehiscence, fracture-related infections), deep vein thrombosis development, hardware irritation, and need for reoperation or revision procedures.

Statistical analysis

Descriptive statistics were calculated for all variables, with continuous variables presented as the means with standard deviations or medians with interquartile ranges on the basis of distribution characteristics. The Shapiro-Wilks test was employed to assess the normality of the data distribution. Baseline demographic and fracture characteristic comparisons between positioning groups were performed via the chi-square test for categorical variables and independent samples t test or the Mann–Whitney U test, as appropriate, for continuous variables. Comparisons of surgical time, hospital stay, postoperative complications, and reoperation rates between groups were conducted via independent samples t tests for normally distributed data or the Mann–Whitney U test for nonparametric variables.

For categorical outcome variables, including complication occurrence and reoperation necessity, the chi-square test or Fisher’s exact test was employed as appropriate on the basis of expected cell frequencies. All statistical tests were conducted via two-tailed analysis, with the significance level set at p < 0.05. Statistical analysis was performed via standard statistical software packages (SPSS Version 26.0, IBM Corporation, Armonk, NY, or equivalent).

Results

Patient Demographics and Injury Characteristics

This comprehensive analysis included 87 patients who underwent surgery for ankle fracture; these patients were distributed between the prone positioning group (n = 45) and the floppy lateral positioning group (n = 42). The prone group had a mean patient age of 47.9 ± 8.4 years, whereas the floppy lateral group had an average age of 45.5 ± 10.1 years. Independent sample t tests revealed no significant difference in age between positioning strategies (p = 0.223), establishing comparable baseline demographic characteristics between cohorts and supporting the validity of the intergroup outcome comparisons.

Baseline fracture characteristics demonstrated substantial comparability between groups. Fracture classification patterns, severity indicators, and injury mechanisms were distributed comparably across both positioning cohorts. This comparable baseline profile indicates that differences in operative outcomes, should they exist, would reflect positioning effects rather than baseline injury severity variation.

Perioperative characteristics

Operative duration analysis demonstrated comparable time requirements between positioning strategies. The prone positioning group required a mean surgical time of 111.9 ± 13.6 minutes from skin incision to closure, whereas the floppy lateral positioning group required an average of 108.6 ± 11.7 minutes. Independent sample t tests revealed no statistically significant difference in operative duration between the groups (p = 0.235), indicating that the patient positioning strategy did not substantially influence the surgical time requirements. The minimal time differential of approximately 3 minutes represents negligible clinical significance and falls well within the expected variation attributable to individual case complexity, surgeon experience variables, and procedural nuances rather than positioning effects.

The fluoroscopic imaging requirements revealed equivalent patterns between the positioning approaches. The prone group demonstrated a mean X-ray exposure time of 39.0 ± 9.0 seconds, whereas the mean X-ray exposure time was 38.4 ± 9.2 seconds in the floppy lateral group (p = 0.761). Statistical comparison via independent samples t test revealed no significant difference in the intraoperative fluoroscopic time between groups. This equivalence in radiation exposure metrics indicates that both positioning strategies provided comparable visualization adequacy for fracture reduction verification without requiring differential imaging frequency or extended fluoroscopic screening time. The interchangeable radiation exposure profiles support positioning selection on the basis of surgeon preference and institutional familiarity rather than imaging requirement considerations.

Postoperative Outcomes and Anatomical Reduction

Radiographic assessment of fracture reduction quality constituted a primary outcome measure, with reduction quality quantified as the percentage of anatomically acceptable alignment across all fracture components. The prone positioning group achieved a mean reduction in quality of 92.77% ± 2.42%, indicating consistently high-quality anatomical alignment across the cohort. The floppy lateral positioning group demonstrated a mean reduction in quality of 92.42% ± 3.08%, reflecting similar, excellent fracture reduction patterns. Independent sample t tests revealed no significant difference in reduction quality between positioning strategies (p = 0.561).

This equivalence in terms of anatomical reduction quality represents a critical finding, as fracture reduction accuracy constitutes the primary determinant of long-term functional outcomes and posttraumatic arthritic progression². The comparable high-quality reductions achieved with both positioning strategies indicate that the positioning choice does not compromise the fundamental surgical objective of restoring normal ankle joint anatomy. Both techniques enable surgeons to achieve anatomically satisfactory reduction in the vast majority of cases, suggesting that the positioning decision can be appropriately based on surgeon comfort, facility infrastructure, and patient safety considerations rather than concerns about reduction quality.

Discussion

Positioning Strategies in Ankle Fracture Surgery and Interpretation of Statistical Equivalence

The selection of patient position represents a fundamental component of surgical planning in the management of complex ankle fractures. Traditional approaches have emphasized prone positioning as the standard configuration for accessing posterior ankle structures. However, this practice has evolved considerably, as surgeons have recognized both the technical advantages and potential complications associated with prolonged prone positioning. Recent investigations examining positioning in trimalleolar fracture surgery have revealed superior outcomes with lateral-to-supine positioning strategies than with purely prone approaches ⁹, suggesting that ongoing refinement of positioning techniques is warranted.

The present investigation demonstrated statistical equivalence between prone and floppy lateral positioning approaches across all measured operative parameters, with no significant differences in surgical time (p = 0.235), radiographic exposure (p = 0.761), or fracture reduction quality (p = 0.561). The lack of statistical significance does not constitute definitive proof of true equivalence, but rather represents preliminary evidence consistent with equivalent outcomes pending confirmation with larger sample sizes. This limitation is particularly relevant given that the observed differences, while not statistically significant, demonstrated a consistent trend favoring the floppy lateral approach (shorter operative time by 3.3 minutes, slightly lower reduction quality by 0.35 percentage points). Future research with adequately powered designs is essential to determine whether these trends reflect true positioning advantages or represent random variation.

The floppy lateral position represents a conceptually intermediate approach that attempts to balance visualization requirements with patient safety considerations. By maintaining patients in a lateral orientation with selective hip elevation, this positioning preserves access to posterolateral structures while maintaining relative accessibility to the medial ankle anatomy. The theoretical advantages are substantial: the floppy lateral position eliminates complete facial downwards positioning, reducing facial edema and associated pressure injuries¹⁰. Additionally, this positioning may reduce intrathoracic and intra-abdominal compression, potentially minimizing the hemodynamic alterations and respiratory compromise associated with extended prone positioning¹¹.

Comparative analysis with other positioning innovations reveals evolving practice patterns. Recent studies documenting lateral-to-supine positioning approaches for trimalleolar fracture fixation reported reduced fluoroscopic requirements, lower postoperative pain scores, and superior radiographic alignment than prone positioning alone ⁹. This emerging evidence suggests that single-position approaches requiring complete prone exposure may not represent the optimal strategy for all surgical scenarios. However, the lateral-to-supine approach requires intraoperative repositioning, which introduces additional time and anaesthesia exposure ⁷.

Complications of Prone Positioning

The prone position carries well-documented risks that warrant consideration during surgical planning. Perioperative visual loss associated with prone positioning represents one of the most serious complications, occurring with variable incidence in different surgical contexts. Posterior ischemic optic neuropathy and other mechanisms of visual loss have been associated with prolonged prone positioning, particularly in procedures exceeding 6-8 hours in duration ¹². While our patient population did not experience visual loss, the risk remains clinically significant with longer procedures.

Facial pressure ulcers constitute another well-documented complication of prone positioning. In prolonged spine surgery via prone positioning, the facial pressure ulcer incidence has been reported to be 27.3%, with hypotension, extended operative time, and crystalloid fluid administration identified as independent risk factors ¹³. While our operative times were relatively modest, the risk remains relevant for more complex cases. Pressure injury prevention requires a meticulous positioning technique with appropriate padding and regular assessment – factors potentially simplified by recovery positioning.

Brachial plexus injury, while less common in ankle surgery than in extended spinal procedures, has been documented in prone positioning scenarios, particularly when arms are positioned across the chest or in dependent positions without adequate padding ⁶. Floppy lateral positioning theoretically reduces this risk through repositioning of the upper extremities and elimination of extreme shoulder positioning.

Hemodynamic alterations associated with prone positioning include increased intrathoracic pressure, reduced venous return, and the potential for hypotension, particularly when combined with anesthesia-induced vasodilation and blood loss ¹⁴. These hemodynamic changes may be less pronounced with recovery, although comparative hemodynamic data between these specific positioning strategies in ankle surgery are lacking.

Surgical Approach Selection and Outcomes

The posterolateral approach has gained increasing popularity for posterior malleolar fracture fixation, enabling direct visualization of articular surfaces, removal of intra-articular debris, and secure plate fixation. Recent data have demonstrated that posterolateral approach fixation yields excellent reduction quality and functional outcomes across various posterior malleolar classification patterns¹⁵. The comparable reduction quality between positioning strategies in the present study suggests that positioning itself is not a primary determinant of reduction quality when an appropriate surgical technique is employed.

Combined posterolateral and medial approaches provide comprehensive access to all three malleolar elements, although coordination between approaches requires careful attention to operative sequencing and positioning stability. The recovery position may offer specific advantages in this setting by maintaining simultaneous anterior-posterior access without requiring intraoperative repositioning.

Recent innovations in approach selection have led to ongoing refinements in surgical techniques. Compared with the single-window technique, the 2-window posterolateral approach resulted in fewer wound complications despite providing adequate visualization ¹⁶. This observation suggests that minimizing soft tissue trauma – potentially achievable through floppy lateral positioning – may yield clinical benefits regardless of the specific fixation technique employed.

Complication Profiles and Risk Factors

Surgical site infection rates following ORIF for ankle fractures average 4-5% in contemporary series, with recognized risk factors including open fracture status, higher ASA classification, comorbid diabetes, and tobacco use ¹⁷. The low infection rates in both groups in the present study reflect the relatively young, healthy patient population typical of trauma centers. Infection risk factors extend beyond positioning strategies, including fracture characteristics, comorbidity burden, and operative factors, including procedural duration and blood loss ¹⁸.

Neurovascular complications, specifically sural nerve injury, represent recognized risks of posterolateral approaches regardless of the positioning strategy used. The comparable sural nerve complication rates between the groups in the present study (p > 0.05) support the concept that neurovascular injury risk is related primarily to surgical technique and exposure selection rather than patient positioning. Recent learning curve analysis of posterolateral approach fixation demonstrated that approach-related complications stabilize after approximately 31 cases in experienced hands ¹⁹, suggesting that surgeon experience substantially influences complication rates.

Functional Outcomes and Long-term Sequelae

The functional outcome data at extended follow-up demonstrated that multiple factors influence post-trimalleolar fracture recovery beyond acute surgical technical factors. Comprehensive long-term follow-up studies indicate that approximately 30% of trimalleolar fracture patients experience inferior functional outcomes at > 15 years ², with outcome quality related to fracture severity, reduced anatomical accuracy, and posttraumatic arthritic development. Neither positioning strategy appeared to influence these long-term prognostic factors in the present series.

The development of posttraumatic arthritis depends primarily on articular surface integrity and long-term joint congruity rather than the positioning strategy. The comparable reduction in quality between the groups suggests equivalent osteoarthritis risk profiles.

Patient Safety and Anesthesia Considerations

From an anesthesia standpoint, recovery positioning may offer advantages over prone positioning. Hemodynamic stability, airway management, and recovery profiles have been shown to differ between positioning strategies ²⁰. Extended prone positioning has been associated with hypotension, facial edema development, and potentially more complicated emergence and recovery patterns. However, comparative anaesthetic outcomes between recovery and prone positioning, specifically in ankle fracture surgery, have not been systematically evaluated.

The decision regarding the positioning strategy optimally incorporates surgeon comfort and familiarity, fracture pattern complexity, patient factors, including body habitus and cardiopulmonary status, and available surgical facilities. No absolute positioning contraindication exists for either strategy in straightforward fracture patterns.

Limitations and conclusions from the present study

Several limitations warrant acknowledgement. The retrospective design precludes randomization and introduces potential selection bias in positioning choice. Surgeon preference for specific positioning strategies may have influenced patient allocation. The relatively modest sample size, while adequate for detecting major differences, may lack the power to identify subtle outcome variations. Functional outcome scoring systems were not uniformly applied in this retrospective cohort, limiting formal functional outcome comparisons. Extended follow-up beyond the acute hospitalization period was not available for all patients.

Despite these limitations, the present investigation provides comparative data supporting the concept that floppy lateral positioning provides clinically equivalent outcomes to traditional prone positioning while potentially reducing the risks associated with prolonged prone positioning. The comparable operative times, hospital stays, reduction quality, and complication rates suggest that the positioning strategy represents a surgeon preference variable rather than a primary determinant of surgical outcome in this patient population.

Conclusions

This study demonstrated that prone and floppy lateral positioning provide comparable outcomes in the operative management of complex ankle fractures, with both approaches achieving similarly high-quality reductions (92.77% ± 2.42% vs. 92.42% ± 3.08%; p = 0.561). The operative efficiency was equivalent between the groups, with mean surgical times of 111.9 ± 13.6 minutes in the prone group and 108.6 ± 11.7 minutes in the floppy lateral group (p = 0.235), as were the comparable fluoroscopic exposure times (39.0 ± 9.0 vs. 38.4 ± 9.2 seconds; p = 0.761). These findings support the practical interchangeability of both positioning strategies, as neither demonstrated superiority in terms of reduction quality, operative duration, or radiation exposure. However, the modest statistical power (0.454) limits the ability to definitively exclude small but clinically meaningful differences. Therefore, positioning selection may reasonably be guided by surgeon preference, institutional experience, and patient-specific safety considerations. Larger prospective studies and adequately powered randomized controlled trials are needed to confirm these findings and establish definitive evidence-based recommendations for optimal positioning in complex ankle fracture fixation.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research received no external funding.

Authors’ contributions

All authors have read and agreed to the published version of the manuscript.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki, Patient data was retrospectively analyzed and did not change patient care. Ethical Committee approval was therefore deemed unnecessary.

History

Received: March 22, 2026

Accepted: May 15, 2026

Published online: June 12, 2026

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