Triple ankle fractures are extremely common in ankle fractures. In recent years, the trend of using the external ankle as the primary surgical treatment has become more and more widely recognized. The clinical diagnosis and surgical treatment experience of 17 cases admitted recently are reported as follows. 1. Clinical data 1.1 General data The 17 cases in this group, 11 male and 6 female, aged 14-65 years, average 38.5 years. All of them were traumatic fresh fractures, among which 4 cases were open fractures. All of them were combined with ankle subluxation. According to the history of trauma, physical signs (such as swelling, clenching test, drawer test and internal and external stress test), X-ray and CT 3D reconstruction, 5 cases were classified according to Lauge-Hansen classification: anterior external rotation type, 6 cases of anterior abduction type, 6 cases of posterior external rotation type, no posterior internal rotation type, and all cases had different degrees of lower tibiofibular joint separation. The remaining 13 cases had swelling and tension blisters on the skin, so they were firstly repositioned manually according to the Lauge-Hansen classification and fixed in a resting position with external plaster, especially if the posterior ankle fracture fragment was larger than 1/4 of the joint surface. This will facilitate the reduction of swelling and repositioning during surgery, and 3D CT reconstruction of the ankle can be done to guide the surgery if possible. In all cases, an incision and internal fixation of the three ankles was performed. Tension screw fixation of the posterior tibial labrum and 1/3 tubular plate fixation of the inferior fibular fracture with oblique distal fibular tension nail fixation of the inferior tibiofibular joint separation, and cancellous bone screw fixation of the medial ankle. Functional exercise was performed early after surgery, and walking exercises were performed 8~10 weeks later. All 17 patients had bony healing, and 12 patients had excellent healing, with anatomical repositioning, ankle dorsiflexion and plantar flexion limitation within 10 degrees, and no pain during activity. The other 5 patients had comminuted fibula fractures or severe separation of the lower tibiofibular joint, and the functional repositioning was limited to 10~20 degrees of ankle dorsiflexion and plantarflexion, and the separation of the lower tibiofibular joint was less than 2 mm, with mild discomfort or soreness after activity. In this group of cases, there was no bone discontinuity or deformity healing and functional instability of the lower tibiofibular joint. Since the distal tension nail was fixed by oblique force separation of the lower tibiofibular joint, no tension screw fracture was found in the second stage of plate removal. 3. Discussion 3.1 Selection of surgical approach All cases in this group used postero-lateral fibular incision plus anteromedial incision of the medial ankle, all of which could be well exposed and operated. The posterior lateral peroneal incision was used to protect the peroneal nerve and the small saphenous vein, and to separate the peroneus longus muscle from the longus flexor of the foot to fully expose the posterior and lateral ankle. Because the fracture mass of the posterior ankle is most often located on the posterior lateral side, the above-mentioned incision can completely expose and no important nerves and blood vessels pass through it except for the terminal branch of the peroneal artery, which is safer and more conducive to repositioning and fixation than the medial transanal canal incision. Compared with the posterior medial incision, the anterior medial incision of the medial ankle, which takes care to protect the saphenous vein and saphenous nerve, has the advantage of allowing direct visualization of the joint surface for repositioning and cleaning the embedded bone fragments and soft tissues, avoiding the surgical operation into the ankle canal and reducing the possibility of damaging important nerves and blood vessels. 3.2 Posterior ankle fractures are mostly avulsion fractures, which are firmly attached by the posterior tibiofibular ligament. As long as the fracture fragment is not too small, it should be fixed with at least one tension screw to increase the stability of the posterior talus of the ankle joint and to avoid the risk of traumatic arthritis later on, regardless of whether the fracture fragment is larger than 1/3 of the articular surface. 3.3 Re-establishment of the lateral complex has been given priority over reconstruction of the medial ankle from a biomechanical point of view. This is because the integrity of the ankle cavity depends on the normal length of the fibula and its precise position in the tibiofibular notch and the integrity of the inferior tibiofibular joint. Most of the triple ankle fractures are combined with separation of the lower tibiofibular joint, external displacement of the outer ankle, and widening of the ankle point, resulting in anterolateral subluxation of the talus within the ankle point, which severely alters the stress distribution of the articular cartilage and is the pathological basis for later traumatic arthritis. Therefore, repositioning and fixing the external ankle and lower tibiofibular joint is the guarantee of a good correspondence between the ankle points. If the lower fibula is oblique, transverse or spiral fracture and can be repositioned anatomically to restore the line of force and length, the outer ankle should be repositioned first and fixed with 1/3 tube plate, and the inner ankle can be repositioned at the same time. If the fibula fracture is comminuted and difficult to be completely anatomically repositioned, the internal ankle is first repositioned and fixed to prevent the talus from shifting outward after the external ankle is not fixed in the anatomical position and the internal ankle alignment cannot be checked. For internal fixation of the external ankle, the 1/3 tubular titanium plate screws are stable and have a certain degree of plasticity, which helps to restore and maintain the length of the fibula and provides excellent fixation. 1/3 tubular plates should be placed on the posterior side of the external ankle in principle, where the bone surface is flat and suitable for placing titanium plates, and the screws at the distal end of the fracture piece can fix the double-layered cortex from posterior to anterior, so it is more solid. In addition, since the fibular stem axis intersects with the lateral ankle axis at an angle of 10-15 degrees, attention should be paid to the outward pre-curvature of the 1/3 tubular plate, otherwise the fibular force line cannot be corrected and the ankle cavity will be easily over-tightened. The author fixed the separated lower tibiofibular joint with one long tension screw. The separation and displacement of the lower tibiofibular joint can be judged based on the overlap of the fibula and anterior tibial tuberosity on preoperative orthopantomographs, as well as on 3D CT reconstructions and preoperative lower tibiofibular joint clenching and separation tests. If there is difficulty, the ankle can be pulled outward by clamping the ankle with a scarf clamp during surgery to determine whether there is excessive movement. In order to allow the ruptured joint ligament to be fully repaired and to prevent the ankle cavity from widening and forming traumatic arthritis, the ligament was replaced by an internal fixation tension screw to stabilize the lower tibiofibular joint. In case of severe separation and displacement, such as partial anterior rotation and external rotation, the screws should pass through four layers of cortex from the fibula to the tibia, and even the lower tibiofibular joint should be locked with bone bolts, especially if all four sets of joint ligaments of the lower tibiofibula are ruptured and completely separated. In the case of mild separation and displacement with only widening of the gap on X-ray, only the three cortical layers of the fibula and tibia on the fibular side should be fixed in order to avoid complete restriction of ankle movement. It is important to note that the joint tension screw must be inserted proximally to the tip of the external ankle, too low may damage the ankle point, while too high tightening may aggravate the separation. When tightening the screws, the ankle joint should be dorsiflexed by 90 degrees or even by 5 degrees to avoid overtightening of the ankle point. This is especially important because a small anterior ankle cavity will prevent the wider anterior talus body from entering the ankle cavity and dorsal extension will be obstructed. In addition, the tension nail repositioned oblique split-force fixation of the lower tibiofibular joint separation is less likely to break during weight bearing than a transverse screw parallel to the ankle joint due to the presence of split forces. Such anatomic repositioning and reliable fixation can ensure ligament healing and connective tissue connection, and the tension screw can be removed before weight bearing after 8-10 weeks to avoid nail breakage.