## 4 Discussion  
Ankle fractures constitute the third most common musculoskeletal injury in the elderly, following hip and distal radius fractures [25]. Recent studies demonstrate a significant increase in the incidence and severity of ankle fractures with age [20; 26]. Among the factors influencing the orthopedic management of ankle fractures in the elderly, a prominent role is played by bone fragility associated with an underlying condition of osteoporosis [27]. This is due to the acknowledged difficulty in achieving stable fixation of osteoporonic bone, necessitating surgical measures to ensure an optimal outcome.  
Ankle fractures in the elderly represent a substantial healthcare burden due to the higher risk of morbidity and mortality [28; 29; 30]. For this reason, it is debated whether this fracture type, akin to the classic triad of proximal femur, vertebrae, and distal radius, can be considered osteoporonic fragility fractures. The hypothesis of this correlation arises primarily due to the fact that ankle fractures are a common low-energy fracture in the elderly and secondly from the observation that these injuries seem to increase, especially in perimenopausal women [31]. This hypothesis is supported also by the anatomical fact that the bony sites involved in these fractures (medial, lateral, and posterior malleoli) consist of a significant proportion of trabecular bone, the bone tissue most early, frequently, and severely affected by osteoporosis.  
Several studies in the literature have sought to evaluate the relationship between these fractures and bone fragility, but their results are conflicting, highlighting a general difficulty in categorizing ankle fractures as osteoporosis-related: some authors support such a correlation reporting a lower BMD and alterations in bone quality in ankle fracture patients [32; 33], while others argue that there is no significant link [34; 35].  
In Italy, Note 79 [36] defines the criteria for prescription and reimbursement by the NHS as limited to conditions of risk of osteoporonic fracture. Fractures eligible for reimbursement for osteoporosis therapy include hip and vertebral fractures, but not other fractures, such as wrist and ankle fractures. This is probably due to the fact that, while hip and vertebral fractures resulting from no or low trauma are easily includable among fragility fractures, for the others the matter is more complex, both because it is not easy to distinguish low- and high-energy traumas (for example, ankle fractures are almost always due to an ankle sprain), and because they are not exclusive fractures of the elderly. From the Swedish register [37], it emerges that hip-fractured patients have an average age of 81.1 years, and the percentage of patients over 65 years is 92.3%; those who undergo a vertebral fracture have an average age of 63, while those over 65 are 53%. Those who undergo an ankle fracture have a much lower average age (52.8), and only 30.5% are over 65. This leads the government system to be cautious on the reimbursement of ankle fractures due to the difficulty in discerning which of these fractures are truly fragility fractures and which are not. The aim of the present study is also to correlate these fractures, based on various parameters, to the actual risk of new fractures, identifying when an ankle fracture can be considered due to fragility.  
As well as for purely health economic reasons, the prevention of osteoporonic fractures is essential to reduce the risks of complications and disability [38].  
This correlation would also influence decisions regarding fracture management, particularly concerning surgical treatment aimed at ensuring stable fixation and an optimal functional outcome.