Arthroscopic-assisted Reduction and Internal Fixation vs Standard Open Reduction and Internal Fixation for Complex Ankle Fractures: A Comparative Cohort Study on Clinical and Radiographic Outcomes

Background: The role of ankle arthroscopy as an adjunct to open reduction and internal fixation (ORIF) for ankle fractures remains debated. This study aimed to compare clinical and radiographic outcomes between arthroscopic-assisted ORIF (AA-ORIF) and standard ORIF for ankle fractures. Methods: A single-center cohort study was conducted from May 2020 to November 2023. A total of 115 patients with unstable ankle fractures were included: 28 underwent AA-ORIF (group I), and 87 underwent standard ORIF (group II). Primary outcomes were the incidence of posttraumatic osteoarthritis (PTOA) and length of hospital stay (LOS). Secondary outcomes included operative time, revision surgery rates, and analysis of confounding variables such as age and fracture pattern. Results: The AA-ORIF group demonstrated a statistically significant reduction in the rate of PTOA (7.1 vs 34.5%, p = 0.003) and a shorter median LOS (6 vs 16 days, p = 0.005). However, the AA-ORIF group was significantly younger (median age 42.5 vs 59 years, p = 0.003) and had a more complex case mix, with a higher proportion of Weber C/Maisonneuve fractures (35.7 vs 9.2%, p = 0.006) and a significantly higher rate of syndesmotic injuries in bimalleolar fractures (71.4 vs 7.9%, p = 0.002). Operative time was longer for AA-ORIF (median 147 vs 117 minutes, p < 0.001). No significant difference was found in revision rates or sex distribution. Conclusion: AA-ORIF was associated with superior early radiographic outcomes (lower PTOA) and a shorter hospital stay. However, significant baseline differences in age and fracture complexity were identified as major confounding factors. While promising, the perceived benefits of AA-ORIF may be influenced by these factors, necessitating further controlled studies to confirm its independent advantage. Level of evidence: Therapeutic level III (retrospective comparative cohort study).