One hundred consecutive patients over the age of 60 years with unstable fractures of the ankle were retrospectively reviewed. Fifty were treated operatively and 50 nonoperatively. The mean follow-up was 7 years (2-16 years). Satisfactory reduction was a prerequisite in both groups. Patient satisfaction with regard to pain, deformity, and stability was significantly better in the operated group. The high proportion of poor final results in the nonoperatively treated group correlated well with malunion and nonunion.