A 36-year-old male presented for follow-up after undergoing open reduction and internal fixation (ORIF) of the right ankle. The patient initially sustained an injury on , 2023, and was treated in the emergency department at the Hospital. Imaging confirmed a displaced lateral malleolus fracture with associated deltoid ligament injury and syndesmotic instability. Given the severity of the injury, he underwent ORIF with lateral malleolus fixation, deltoid ligament repair, and syndesmosis stabilization.
At his first post-operative visit, the patient reported well-controlled pain, no secondary trauma, and minimal swelling. He was compliant with post-operative instructions, wearing a splint and remaining non-weight-bearing as directed. He denied any fever, chills, or systemic symptoms, and there was no drainage from the incisions.
The patient was an otherwise healthy young adult with no significant past medical history. He led an active lifestyle before his injury, participating in recreational sports and outdoor activities. His primary concern was returning to full function as soon as possible, as he was unable to bear weight on his affected limb, limiting his daily activities.
Initial Post-Operative Assessment
On physical examination, the surgical incision was well-healed without signs of infection. There was moderate swelling around the ankle and mild ecchymosis from prior cast placement. Palpation revealed tenderness along the lateral malleolus and deltoid ligament, but no severe pain with passive movement. Range of motion was moderately restricted, and strength was reduced compared to the contralateral limb. However, distal pulses were palpable, and neurological function was intact.
Radiographic Findings
ORIF hardware in place with no evidence of loosening or malalignment
Well-maintained ankle mortise
No signs of infection, osteolysis, or hardware complications
Given his progress, the decision was made to transition him into a pneumatic walking boot. He was instructed to remain non-weight-bearing for another two weeks while continuing gentle range-of-motion exercises to prevent stiffness.
Follow-Up Progression
Two Weeks Post-Operative Visit
At his two-week follow-up, the patient reported continued improvement, with minimal pain at rest and occasional discomfort with movement. Sutures were removed, and there was no evidence of infection or wound complications. The splint was discontinued, and he was fitted for a pneumatic boot. He was advised to continue non-weight-bearing for an additional two weeks.
Four Weeks Post-Operative Visit
By four weeks post-op, the patient had maintained good compliance with post-operative care. He noted mild stiffness in the ankle but no significant pain at rest. Swelling had improved, though still present with prolonged dependency. At this stage, he was cleared to begin transitioning to weight-bearing as tolerated while still using the boot. Gentle range-of-motion exercises were encouraged to prevent stiffness and maintain mobility.
Eight Weeks Post-Operative Visit
At eight weeks post-op, the patient reported increased confidence with walking. He had transitioned to full weight-bearing in the boot and was actively participating in physical therapy. Examination showed mild residual swelling, but he had regained significant mobility. Strength was improving, though not yet symmetrical to the contralateral limb. He was advised to wean off the boot and begin progressive strengthening exercises in therapy.
Twelve Weeks Post-Operative Visit
By twelve weeks, the patient had made notable progress. He had discontinued the boot and was ambulating independently. Swelling was minimal, and strength continued to improve with rehabilitation. More aggressive physical therapy was initiated, focusing on balance training and functional movement to restore stability. While he experienced mild stiffness in the mornings, he had no significant pain with daily activities.
Sixteen Weeks Post-Operative Visit
At sixteen weeks, the patient had resumed most of his pre-injury activities, including light jogging and recreational sports. His range of motion was near normal, and strength had significantly improved. There was no longer any swelling at rest, though he experienced mild discomfort after prolonged activity. He was encouraged to continue strengthening and proprioceptive training.
Six-Month Follow-Up
At his six-month follow-up, the patient had successfully returned to his regular lifestyle with full functional recovery. He no longer experienced significant pain, and any mild discomfort was managed with stretching and orthotics. His range of motion was fully restored, and he expressed great satisfaction with his progress.
Rehabilitation Plan and Long-Term Outcome
The patient was prescribed a structured rehabilitation program, including:
Strengthening exercises to improve ankle stability and mobility.
Gradual return to full weight-bearing activities over the next 4-6 weeks.
Balance training to enhance proprioception and reduce the risk of reinjury.
Monitoring for potential complications such as persistent stiffness or instability.
Despite early challenges, the patient’s commitment to physical therapy contributed to his successful recovery. He continues to follow up as needed for long-term monitoring.
Conclusion
This case highlights the importance of early surgical intervention for severe ankle fractures, as well as the necessity of a structured rehabilitation program. Despite the complexity of his injury, the patient achieved excellent functional recovery through careful post-operative management and dedicated rehabilitation. His outcome reinforces the effectiveness of surgical stabilization for syndesmotic injuries and the critical role of guided physical therapy in optimizing post-surgical mobility and strength.
Disclaimer: Patient’s name, age, sex, dates, and events have been modified to protect patient privacy.
Dr. Mo Athar
