## 4 Discussion
### Ankle Fractures and Osteoporosis  
The risk of future fragility fractures can be weighed based on BMD, measured with the DXA method, or with risk assessment tools, such as the FRAX(r) algorithm.  
In the literature, the relationship between reduced BMD and ankle fractures is contrasting [39]. Patients in our study show that ankle fractures in the elderly are most frequent with reduced BMD (76.5% of the total patients examined, 83.8% considering only women). These results find confirmation, among others, in the comprehensive and extensive study conducted by [PERSON] between 1970 and 2014 in the Finnish population [40], which enhances this association in particular for postmenopausal women.  
In our osteoporoporotic patients, we further observed that fracture complexity was heightened, with 70% of their fractures classified as trimalleolar with only 20% and 10% mono- and bimalleolar, respectively. These fractures thus appear to exhibit greater complexity as bone mass decreases, as suggested also by [PERSON] et al. [41] in their study based on CT scan images of such fractures.  
In our experience, a correlation also emerged between patients with lower values of BMD and those with low-energy traumas (82%). Similarly, [PERSON] et al. observed that the majority of ankle fractures in women over 65 years of age are attributed to minor or low-energy trauma [42].  
Regarding the calculation of the risk of future fragility fractures at 10 years calculated by the FRAX(r) algorithm, we found that the low-energy trauma group had a significantly higher average risk compared to the high-energy trauma group (10.8% vs. 6.2%). To support our data, [PERSON] et al. found that the likelihood of experiencing additional fractures following an ankle fracture is increased when the fracture results from low-energy trauma rather than severe trauma [43]. These results seem to suggest that these fractures exhibit typical characteristics of fragility fractures, which are indeed associated with a higher risk of refracture [31; 44].  
To summarize, the results of our study suggest a correlation between ankle fractures in the elderly and osteoporosis. Specifically, suspicions of a connection with osteoporosis should arise, especially in older women with trimalleolar fractures resulting from low-energy traumas. This suspicion should increase further in the case of previous fragility fractures as confirmed by FRAX(r) results, based also on the investigation of previous osteoporoporotic fractures.  
However, based on the results obtained, it is not possible to definitively categorize ankle fractures in the elderly as typical fragility fractures within the examined sample, and the debate is still open. Based on our results, we suggest that it might be advisable to initiate a comprehensive fracture risk assessment in elderly patients who experience an ankle fracture [45]. This could potentially lead to the implementation of both pharmacological and non-pharmacological secondary prevention measures to reduce the incidence of falls and mitigate their consequences [46; 47]. From an orthopedic perspective, in the case of surgical treatment, strategies aimed at ensuring stable fixation should be considered [48], given the often more fragile nature of the bones involved [49].