Bicortical fixation of medial malleolar fractures: a review of 23 cases at risk for complicated bone healing

Current Concepts in Ankle Fracture Management

Ankle fractures are one of the more common musculoskeletal injuries that are treated by foot and ankle specialists. A thorough understanding of managing these injuries requires the ability to differentiate between stable and unstable fractures. The current literature supports the nonoperative management of stable Weber B ankle fractures, whereas unstable fractures have much better outcomes with surgical intervention. Specifically, we review the fixation strategies for the lateral, medial, and posterior malleolar fractures respectively. Finally, we discuss the current trends in postoperative management of some of the more common fracture patterns, and the safety in early weight-bearing protocols.

Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures: A Randomized Clinical Trial

Importance

Unstable ankle fractures are routinely managed operatively. However, because of soft tissue and implant-related complications, recent literature has reported on the nonoperative management of well-reduced medial malleolus fractures after fibular stabilization, but with limited evidence supporting the routine application.

Objective

To assess the superiority of internal fixation of well-reduced (displacement ≤2 mm) medial malleolus fractures compared with nonfixation after fibular stabilization.

Design, Setting, and Participants

This superiority, pragmatic, parallel, prospective randomized clinical trial was conducted from October 1, 2017, to August 31, 2021. A total of 154 adult participants (≥16 years) with a closed, unstable bimalleolar or trimalleolar ankle fracture requiring surgery at an academic major trauma center in the UK were assessed. Exclusion criteria included injuries with no medial-sided fracture, open fractures, neurovascular injury, and the inability to comply with follow-up. Data analysis was performed in July 2022 and confirmed in September 2023.

Interventions

Once the lateral (and where appropriate, posterior) malleolus had been fixed and satisfactory intraoperative reduction of the medial malleolus fracture was confirmed by the operating surgeon, participants were randomly allocated to fixation (n = 78) or nonfixation (n = 76) of the medial malleolus.

Main Outcome and Measure

Olerud-Molander Ankle Score (OMAS) 1 year after randomization (range, 0-100 points, with 0 indicating worst possible outcome and 100 indicating best possible outcome).

Results

Among 154 randomized participants (mean [SD] age, 56.5 [16.7] years; 119 [77%] female), 144 (94%) completed the trial. At 1 year, the median OMAS was 80.0 (IQR, 60.0-90.0) in the fixation group compared with 72.5 (IQR, 55.0-90.0) in the nonfixation group (P = .17). Complication rates were comparable. Significantly more patients in the nonfixation group developed a radiographic nonunion (20% vs 0%; P < .001), with 8 of 13 clinically asymptomatic; 1 patient required surgical reintervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome.

Conclusions and Relevance

In this randomized clinical trial comparing internal fixation of well-reduced medial malleolus fractures with nonfixation, after fibular stabilization, fixation was not superior according to the primary outcome. However, 1 in 5 patients developed a radiographic nonunion after nonfixation, and although the reintervention rate to manage this was low, the future implications are unknown. These results support selective nonfixation of anatomically reduced medial malleolar fractures after fibular stabilization.

Trial Registration

ClinicalTrials.gov Identifier: NCT03362229.

Preoperative Computed Tomography in Guiding the Length of Cannulated Screws in Medial Malleolar Fractures

Excessive lengths of partially threaded cannulated screws in medial malleolus fractures are often related to failure of fixation. This study aimed to analyze the distribution and density of cancellous bone in the medial malleolus among healthy individuals and provide a theoretical basis for determining the lengths of cannulated screws based on preoperative computed tomography (CT) to achieve stable fixation of medial malleolus fractures. Between January 2012 and December 2016, 100 patients (without ankle fractures) who underwent computed tomography of the distal tibia were included. Specific levels on the computed tomography images were selected to assess the density and length of valid cancellous bone in the medial malleolus. Meanwhile, we followed up 44 patients who underwent open reduction and internal fixation of medial malleolus fractures based on preoperative computed tomography-based measurements. The valid lengths of cancellous bone in the medial malleolus were significantly different between men and women (p < .05). In addition, there was a significant difference among different age groups (p < .05). All patients were followed up to union without displacement. Age and gender have a considerable impact on the distribution and density of cancellous bone in the medial malleolus. The density and length of valid cancellous bone decrease with age. The shoulder of the tibial plafond in medial malleolus, which is a weak part of cancellous bone, is a common site of fracture. Short screws are recommended for fixation in elderly patients. In conclusion, preoperative computed tomography can help determine the length and location of cannulated screws.

Efficacy of hook-type locking plate and partially threaded cancellous lag screw in the treatment of displaced medial malleolar fractures in elderly patients

INTRODUCTION

Traditionally, partially threaded cancellous lag screws (PTCS) are used for most medial malleolar fractures but are often challenging to execute in elderly patients because of the high risk of postoperative complications. Limited literature explores whether hook-type locking compression plates (LCPs) reliably offer better outcomes than PTCS in elderly patients. We aimed to compare the midterm radiologic and clinical outcomes between hook-type LCP and PTCS for medial malleolar fractures in an elderly population.

METHODS

We included 258 patients, aged 65 years and above, treated with either a hook-type locking plate (hook LCP group: 121 patients) or PTCS (screw group: 137 patients), and with follow-ups of at least 36 months in this retrospective study. Radiographic assessments included the union rate and interval to fracture union. Clinical assessment included the postoperative complications and revision procedures.

RESULTS

Although a significantly higher rate of comminuted fractures was observed in the hook LCP group than in the screw group (p < .001), no significant difference in the union rate was observed between the two groups (hook LCP group: 93.4% vs. screw group: 89.8%, p = .151), and a significantly shorter interval to union was observed in the hook LCP group (10.2 ± 7.0 vs. 12.3 ± 6.7 weeks, p = .015). There was a trend toward a lower rate of complications, including revision procedures, in the hook LCP group than in the screw group (19.9% vs. 28.5%, p = .107 and 6.6% vs. 13.8%, p = .074).

CONCLUSION

Hook-type LCP may be an alternative option for treating medial malleolar fractures with comminution in elderly patients.

The Surgical Outcomes of Unstable Ankle Fractures in Patients Aged >65 Years

AIM

To evaluate the surgical outcomes and complications of patients over 65 years of age, with unstable ankle fractures.

MATERIAL AND METHOD

The study included 111 patients (73F/38 M) operated on between January 2015 and February 2019 and followed up for a mean of 21.2 months (range, 6-62 months).Demographic characteristics, comorbidities, fracture type, and mechanisms of injury were evaluated. Relationships between postoperative complications and comorbidities were examined. In the postoperative functional evaluations, the AOFAS score was used and pre and postoperative mobilization (eg, use of assistive devices) was assessed.

RESULTS

The mean age of the patients was 70.5 ± 6.1 years (range, 65-90 years). The mechanism of trauma was low-energy trauma in 90.1% of the fractures and high-energy trauma in 9.9%. The fractures were formed with a SER injury (supination external rotation) in 83.7% of cases and bimalleolar fractures were seen most frequently (85/111, 76%).Complications developed in 16 (14.4%) patients and a second operation was performed in 11 (9.9%) patients with complications. Plate was removed and debridement was performed in 5 of 6 patients due to wound problems. Nonunion was developed in the medial malleolus in 4 patients. Revision surgery was performed because of implant irritation in 2 patients and early fixation loss in the medial malleolus fracture in one patient. Calcaneotibial arthrodesis was performed in 3 patients because of implant failure and ankle luxation associated with non-union. A correlation was determined between ASA score and DM and complications, but not with osteoporosis. The mean follow-up AOFAS score was 86.7 ± 12.5 (range, 36-100).A total of 94 (84.7%) patients could walk without assistance postoperatively and 92 (82.9%) were able to regain the preoperative level of mobilization.

CONCLUSION

Although surgery can be considered an appropriate treatment option for ankle fractures in patients aged >65 years, care must be taken to prevent potential complications and the necessary precautions must be taken against correctable comorbidities.

Current concepts and challenges in managing ankle fractures in the presence of diabetes: A systematic review of the literature

BACKGROUND

Ankle fractures in diabetic patients are known to have an increased morbidity. This systematic review aims to evaluate the current evidence in terms of risk profile and inform treatment options.

METHODS

Following the methodology of the Cochrane collaboration, an extensive literature search was conducted. Outcomes included, complications, operative and non-operative management and early weight-bearing.

RESULTS

A total of 40 studies were included. Complication rates were higher in diabetic patients and more so in poorly controlled diabetes, IDDM, or "complicated" diabetes. Supplementary fixation was associated with lower complication rates. Regarding early weight-bearing, similar results to non-diabetics in the stable fracture pattern were found providing there was no evidence of neuropathy.

CONCLUSION

Diabetes, especially complicated diabetes, presents an increased risk of complications. However non operative management of diabetic ankle fractures do poorly, and with the use of 'ORIF plus' techniques there is no increase in complications from early fixation. The use of external fixation for definitive fixation should be minimised as it is associated with high complication rates.

Comparison of Partially Threaded and Fully Threaded 4mm Cancellous Screws in Fixation of Medial Malleolar Fractures

Background

Several devices have been described for fixation of displaced medial malleolar fractures. Fully threaded cancellous screws engaging the bone may provide advantages compared to partially threaded screws. This study was designed to compare the clinical results of fully and partially threaded 4 millimeter cancellous screws in fixation of medial malleolar fractures.

Methods

In a randomized clinical trial study 44 patients with displaced closed medial malleolar fractures were randomly divided into two groups. Two fully threaded four millimeter cancellous screws were used for fracture stabilization (FT group) in the first group, while, the second group was operated by use of two partially threaded four millimeter cancellous screws (PT group). The clinical outcomes and complications were compared in two groups at one year follow up.

Results

Nineteen patients in FT group and 21 in PT group were present at final follow up. Nonunion was not developed in either group but two cases (9%) of delayed union occurred in PT group. The rate of postoperative infection and symptomatic hardware were not statistically different. Functional assessment using AOFAS, MOXFQ and VAS scores showed no significant difference between the two groups.

Conclusion

Both fully and partially threaded 4 mm cancellous screws can be considered as acceptable devices for the fixation of medial malleolar fractures with good and comparable clinical results.

The Role of Far Cortical Endosteal Fixation for the Treatment of Medial Malleolus Fractures: A Biomechanical Study

The traditional method for fixation of medial malleolus fractures has been with partially threaded (PT) lag screws extending beyond the physeal scar. The purpose of this study was to evaluate the biomechanical strength of an innovative method of fixation for medial malleolus fractures using a fully threaded (FT) lag screw that extends to the far endosteal cortex. Medial malleolus fractures were simulated in 12 matched cadaver pairs. A single PT 4.0-mm cancellous lag screw was placed in 1 ankle. The contralateral ankle of the same matched pair received an FT 3.5-mm cortical lag screw that extended to the far lateral tibial cortex and achieved endosteal purchase. Final torque of both screw configurations was recorded, and radiographs were taken to confirm appropriate screw placement. Average torque for the PT cancellous screws was 5.02 ± 2.34 in-lb. Average torque for the FT cortical screw was 7.63 ± 3.86 in-lb (p = .002). Visual and radiographic inspections revealed no displacement of the fracture site with use of the FT endosteal lag screw. Our results indicate superior biomechanical torque with far endosteal fixation with use of an FT cortical lag screw versus a traditional PT cancellous lag screw in a cadaver model. Far endosteal fixation is an alternative surgical option for medial malleolus fractures that provides added strength compared with PT lag screws and may obviate downsides associated with bicortical fixation.

Biomechanical Comparison of Locking Plate and Cancellous Screw Techniques in Medial Malleolar Fractures: A Finite Element Analysis

As the commonly used fixation strategy of medial malleolar fractures, cancellous screws (CS) have been challenged for instability, bone destruction, and metal prominence. It is still unclear whether a locking compression plate (LCP) is a better choice in such fractures. Our purpose is to compare the mechanical efficacy of LCP with traditional 4.0-mm CS for transverse, oblique, and vertical medial malleolar fractures by using finite element analysis. In this study, 3-dimensional models of the distal tibia were reconstructed from a computed tomography scan of a young healthy male adult. Conditions included 3 fracture lines at 30°, 60°, and 90°; 2 groups of fixation (LCP and CS); and 3 adduction loads of 300, 500, and 700 N applied to the medial malleolar joint surface. The proximal part of the tibia was fixed for all degrees of freedom. The fracture displacements of the LCP were smaller than those of CS (p < .05). The stiffness of the LCP constructs was much higher than that of the CS constructs, especially in the 90° fractures (490.3 versus 163.6 N/mm). The mean stress around the CS was higher than that in LCP for 60° and 90° fractures, but there was no difference for 30°. Maximal bone stress increased (19.84 to 50.86 MPa) and concentrated on cortical bone in LCP, whereas it concentrated on cancellous bone in CS. The results showed that LCP could improve stability, preventing bone destruction in oblique and vertical medial malleolar fractures. However, in transverse fractures, CS provides sufficient stability, with no need to use LCP.

Medial malleolus: Operative Or Non-operative (MOON) trial protocol - a prospective randomised controlled trial of operative versus non-operative management of associated medial malleolus fractures in unstable fractures of the ankle

BACKGROUND

There are limited data reporting the outcome of patients with non-operatively managed medial malleolus fractures compared to those treated surgically in the presence of fibular stabilisation for unstable fractures of the ankle. Conservative management could result in fewer complications, reduced surgical time and lower cost. The purpose of this study is to determine if any difference exists in patient reported and surgical outcomes 1 year after surgery between operative and non-operative treatment of medial malleolar fractures in combination with stabilisation of the lateral malleolus.

METHODS/DESIGN

This is a single-centre, prospective, randomised controlled trial that aims to randomise 154 participants with an unstable ankle fracture to 'non-fixation' (n = 77) or 'fixation' (n = 77) of an associated well-reduced medial malleolus fracture following fibular stabilisation. The study will include patients ≥ 16 years of age with a closed bimalleolar or trimalleolar ankle fracture who are able to consent, complete questionnaires in the English language, and complete follow-up over a 1-year period. Randomisation will occur intra-operatively when the medial malleolus fracture is deemed 'well-reduced', with 2 mm or less of fluoroscopic displacement. The technique for fixation of both the medial and lateral malleoli is at the discretion of the operating surgeon. Patient-reported, observer-rated, and radiographic assessments will be collected at baseline and then at the following post-operative assessment points: 2 weeks, 6 weeks and 1 year. Postal questionnaire outcome data will be collected at 3 and 6 months. The primary outcome measure will be the Olerud Molander Ankle Score (OMAS) at 1 year following surgery. Secondary outcome measures will include the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5D (EQ-5D), pain, treatment satisfaction, time to return to activity, operative tourniquet time, and complications.

DISCUSSION

There is only one previous randomised trial comparing non-fixation with fixation of associated medial malleolus fractures but that was limited by the lack of baseline patient-reported outcome data and an inferior sample size. This current prospective trial aims to provide high-quality evidence regarding the requirement for medial malleolar fixation in unstable ankle fractures.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03362229 . Registered retrospectively on 5 December 2017.

Medial malleolar fractures: current treatment concepts

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: Bone Joint J 2019;101-B:512-521.

Radiographic Results of Unicortical Medial Malleolar Fracture Fixation

BACKGROUND:

Medial malleolar fractures commonly occur as part of rotational ankle fractures, which often require surgery. Different fixation techniques exist, including unicortical or bicortical lag-screw fixation. Bicortical screws that engage the lateral distal tibia have been noted to be biomechanically superior to unicortical ones with a lower failure rate. The authors of this study have used unicortical screws routinely. This study was initiated to investigate the clinical results of a large series of patients with unicortical medial malleolar fixation.

METHODS:

Patients who underwent unicortical medial malleolar fracture fixation between 2011 and 2017 were reviewed. In total, 461 ankle fractures were identified with a mean follow-up of 11.4 months (range, 3-57), of which 211 had a medial malleolar fracture. Eight patients were excluded as they did not follow up with the treating surgeons after surgery, leaving 203 patients for evaluation. The primary outcome was radiographic union. Any loss of reduction, complication, or subsequent surgery was recorded. Malunion was defined as greater than 2 mm displacement.

RESULTS:

There were 2 asymptomatic nonunions (1.0%), 1 delayed union that healed using an external bone growth stimulator (0.5%), and 2 malunions of the medial malleolus (1.0%) with 1 asymptomatic. The other patient developed posttraumatic osteoarthritis but has not yet required further surgery. None of these 5 patients required revision medial malleolar surgery. Ultimately, the union rate using unicortical medial malleolar fixation was 99.0% (201/203).

CONCLUSION:

Unicortical fixation of medial malleolar fractures resulted in consistently good healing. Even though biomechanical studies have shown that bicortical screws provide stronger fixation, our clinical results indicate that the need for this stronger fixation may be questionable.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Adverse Radiographic Outcomes Following Operative Treatment of Medial Malleolar Fractures

BACKGROUND

We initiated a retrospective study on ankle fractures to assess (1) the time needed for fracture union; (2) the incidence of adverse radiographic outcomes (AROs); (3) factors that might lead to AROs; and (4) whether AROs were associated with worse function and higher incidence of post-trauma osteoarthritis (PTOA).

METHODS

From 2007 to 2016, a total of 296 patients (169 women, 127 men; average age, 48.6 years; range, 20-84) were diagnosed with a medial malleolar fracture, whether isolated or in the setting of bi- or trimalleolar fractures, and underwent open reduction and internal fixation (ORIF) or percutaneous screw fixation (PSF). The interval to fracture union, radiographic outcomes, American Orthopaedic Foot & Ankle Society (AOFAS) score at 6 months postoperatively, and the incidence of PTOA were recorded. Risk factors were identified both in univariate and multivariate analysis. The average follow-up period was 52.0 months (range, 12-118).

RESULTS

The incidence of delayed union, nonunion, and malunion were 20.3%, 3.7%, and 4.4%, respectively. The interval to fracture union was 10.3 ± 6.4 weeks. In the multivariate analysis, the risk factors for AROs were tobacco use, vertical fractures, interposed soft tissue, and fair/poor reduction. Patients with AROs had significantly worse AOFAS score at 6 months postoperatively ( P < .001) and higher incidence of PTOA ( P < .001).

CONCLUSION

AROs of medial malleolar fractures have an underestimated incidence rate and are associated with worse ankle function and higher incidence of PTOA. Risk factors including tobacco use, vertical fractures, interposed soft tissue, poor/fair reduction should be prudently taken into consideration when treating medial malleolar fractures.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Isolated Medial Malleolus Fractures: Conventional Techniques Versus Headless Compression Screw Fixation

The aim of the present study was to evaluate the clinical and radiologic results of surgically treated isolated medial malleolar fractures and compare the clinical and radiologic results of the fixation methods of headless cannulated fully threaded compression screws and cancellous lag screws and tension band wiring. We included 32 patients who attended the final follow-up examination. Group 1 consisted of 11 patients (34.4%) treated with headless cannulated fully threaded compression screws. Group 2 consisted of 10 patients (31.2%) treated with cancellous lag screws. Group 3 consisted of 11 patients (34.4%) treated with Kirschner wires and intraosseous tension wiring. Standard ankle radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and visual analog scale for pain were assessed. No statistically significant differences were found among the groups in regard to age, gender, preoperative fracture type, follow-up time, radiologic bone union time, and baseline AOFAS scale scores. The interval to fracture healing was 2.2 ± 0.42 months in group 1, 2.5 ± 0.71 months in group 2, and 2.45 ± 0.52 months in group 3. The AOFAS ankle-hindfoot scale score was 96.73 ± 5.55 in group 1, 93.1 ± 5.43 in group 2, and 93.73 ± 5.52 in group 3. Hardware removal was not required in any patient in group 1 but was required in 2 patients (20%) in group 2 and 3 patients (27.3%) in group 3. The visual analog scale score for pain on palpation at the medial malleolus was significantly lower statistically in the headless compression screw group (group 1; p = .003).

Mini-Fragment Fixation Is Equivalent to Bicortical Screw Fixation for Horizontal Medial Malleolus Fractures

Horizontal fractures of the medial malleolus occur through application of valgus or abduction force through the ankle that creates a tension failure of the medial malleolus. The authors hypothesize that mini-fragment T-plates may offer improved fixation, but the optimal fixation construct for these fractures remains unclear. Forty synthetic distal tibiae with identical osteotomies were randomized into 4 fixation constructs: (1) two parallel unicortical cancellous screws; (2) two parallel bicortical cortical screws; (3) a contoured mini-fragment T-plate with 2 unicortical screws in the fragment and 2 bicortical screws in the shaft; and (4) a contoured mini-fragment T-plate with 2 bicortical screws in the fragment and 2 unicortical screws in the shaft. Specimens were subjected to offset axial tension loading on a servohydraulic testing system and tracked using high-resolution video. Failure was defined as 2 mm of articular displacement. Analysis of variance followed by a Tukey-Kramer post hoc test was used to assess for differences between groups, with significance defined as P<.05. The mean stiffness (±SD) values of both mini-fragment T-plate constructs (239±83 N/mm and 190±37 N/mm) and the bicortical screw construct (240±17 N/mm) were not statistically different. The mean stiffness values of both mini-fragment T-plate constructs and the bicortical screw construct were higher than that of a parallel unicortical screw construct (102±20 N/mm). Contoured T-plate constructs provide stiffer initial fixation than a unicortical cancellous screw construct. The T-plate is biomechanically equivalent to a bicortical screw construct, but may be superior in capturing small fragments of bone. [Orthopedics. 2018; 41(3):e395-e399.].

Medial Malleoli Fractures: Clinical Comparison Between Newly Designed Sled Device and Conventional Screws

BACKGROUND

The Trimed Medial Malleolar Sled is a newer device designed to treat medial malleolus fracture. The purpose of this study was to compare the outcome of medial malleolar fractures treated with the sled and conventional malleolar screws.

METHODS

After obtaining an institutional review board approval, we conducted a retrospective study to identify all skeletally mature patients who sustained an ankle fracture with medial malleolar involvement treated with the sled and we identified a matched cohort treated with conventional malleolar screws. The patients were divided into 2 groups: group A included patients treated with malleolar screws and group B included patients treated with the sled device. The outcomes measured included rate of union, implant removal, and pain over the implant site.

RESULTS

Eighty-five medial malleolar ankle fractures were divided into 2 groups: group A included patients (n = 64) treated with malleolar screws and group B included patients (n = 21) treated with the sled device. In group A (n = 64), 62 patients (96.8%) achieved radiological union with a mean union rate of 11 weeks and 10 (15%) patients underwent repeat surgery for implant removal of which 3 patients (4.6%) had pain specifically over the medial implant. In group B (n = 21), all of the patients (100%) achieved radiological union with a mean union rate of 10.8 weeks and 3 patients (14.2%) underwent repeat surgery of which 1 (4.7%) was related to the medial pain. There is no significant difference between the groups for the outcomes measured, including rate of union (  P = .93), visual analog scale score for pain (  P = .07), implant removal (  P = .41), and pain over the implant site (  P = .88).

CONCLUSION

Based on the data from our study, we conclude that there are no major differences between the sled devices and conventional screws relating to union rate and complications.

LEVELS OF EVIDENCE

Level III: Observational study.

Comparison of Medial Malleolar Fracture Healing at 8 Weeks After Open Reduction Internal Fixation Versus Percutaneous Fixation: A Retrospective Cohort Study

Unstable medial malleolar fractures are treated with either standard open reduction internal fixation (ORIF) or a percutaneous approach. The percutaneous approach avoids the potentially excessive soft tissue dissection associated with an open approach but can also result in inadequate anatomic reduction. No studies have compared the incidence of radiographic healing of medial malleolar fractures between an open approach and percutaneous fixation. A retrospective comparative study was performed at a single institution across multiple sites. Electronic medical records and digital radiographs were reviewed for 845 patients who had undergone either ORIF or percutaneous screw fixation (PSF) of a medial malleolar fracture. The interval to fracture healing was measured. Logistic regression analysis was used. Of the 490 included patients, 458 (93.44%) underwent standard ORIF and 32 (6.53%) underwent PSF. Patients who underwent ORIF were 5 times more likely to have a healed fracture at 8 weeks than were patients who had undergone PSF (p < .001). Compared with standard ORIF, PSF of medial malleolar fractures leads to an increased risk of an unhealed fracture at 8 weeks. This was likely due to a combination of soft tissue interposition within the fracture site and inadequate fluoroscopic reliability, leading to poor anatomic reduction and inaccurate fixation.

Comparing the Knotless Tension Band and the Traditional Stainless Steel Wire Tension Band Fixation for Medial Malleolus Fractures: A Retrospective Clinical Study

The traditional stainless steel wire tension band (WTB) has been popularized for small avulsion fractures at the medial malleolus. Despite the tension band principle creating a stable construct, complications continue to arise utilizing the traditional stainless steel WTB with patients experiencing hardware irritation at the tension band site and subsequent hardware removal. Coupled with hardware irritation is fatigue failure with the wire. The goal of this investigation was to retrospectively compare this traditional wire technique to an innovative knotless tension band (KTB) technique in order to decrease costly complications. A total of 107 patients were reviewed with a minimum follow-up of 1 year. Outcome measures include descriptive data, fracture classification, results through economic costs, and fixation results (including hardware status, healing status, pain status, and time to healing). The KTB group had a 13% lower true cost as compared to the WTB group while the fixation results were equivocal for the measured outcomes. Our results demonstrate that the innovative KTB is comparable to the traditional WTB while offering a lower true cost, an irritation free reduction all without the frustration of returning to the operating room for additional hardware removal, which averages approximately to $8,288.

Treatment of Nonunions After Malleolar Fractures

Ankle fracture nonunion is a rare occurrence following closed or operative intervention. When it does occur, patients can experience debilitating symptoms that limit daily function. Malleolar nonunion can be caused by patient factors, such as smoking, malnutrition, or vascular insufficiency. Surgeon factors, such as insufficient or inappropriate operative fixation, also play a role. Several adjuncts, such as bone grafting, bone morphogenic protein, and bone stimulation, are useful in treating nonunions. Through a multimodal approach, malleolar nonunions are reliably treated with operative fixation leading to good patient outcomes with minimal complications.

Anterograde Headless Cannulated Screw Fixation in the Treatment of Medial Malleolar Fractures: Evaluation of a New Technique and Its Outcomes

OBJECTIVE

To evaluate the functional and radiological outcomes of anterograde headless cannulated screw fixation for medial malleolar fractures.

SUBJECTS AND METHODS

This study included 12 patients (8 males, 4 females; age 27-55 years) with medial malleolar type B fractures according to the Herscovici fracture classification who had undergone anterograde headless cannulated screw fixation surgery between 2012 and 2014. Seven had an isolated medial malleolar fracture and 5 a bimalleolar fracture. All of the bimalleolar fractures were classified as 44-B2 based on the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification. Postoperatively, bone union was evaluated on direct radiographs at the final follow-up examination. The American Orthopaedic Foot and Ankle Society (AOFAS) scoring system was used for clinical evaluation.

RESULTS

The mean follow-up period was 17.2 ± 5.3 months (range 12-23). Full union was achieved in all fractures. The mean time to union was 3.4 ± 1.5 months (range 2-5). No instability, loss of reduction, non-union or infection was observed in any patient. The mean AOFAS score was 95.0 ± 5.4 (range 87-99). Based on the AOFAS score, 4 patients showed good results and 8 excellent results. The mean time to return to the previous level of activity was 4.0 ± 2.5 months (range 2-5).

CONCLUSION

In this study, anterograde headless cannulated screw fixation yielded good clinical outcome in the surgical treatment of Herscovici type B fractures.

Internal fixation of osteoporotic fractures

Osteoporosis leads to bone fragility and increased risk of fracture. Despite advances in diagnosis and treatment, the prevalence continues to rise. Osteoporotic fracture treatment has a unique set of difficulties related to poor bone quality and traditional approaches, and implants may not perform well. Fixation failure and repeat surgery are poorly tolerated and highly undesirable in this patient population. This review illustrates the most recent updates in internal fixation, implant design, and surgical theory regarding treatment of patients with osteoporotic fractures.

Mechanism and Treatment Strategy of Osteoporosis after Transplantation

Osteoporosis (OP) has emerged as a frequent and devastating complication of organ solid transplantation process. Bone loss after organ transplant is related to adverse effects of immunosuppressants on bone remodeling and bone quality. Many factors contribute to the pathogenesis of OP in transplanted patients. Many mechanisms of OP have been deeply approached. Drugs for OP can be generally divided into "bone resorption inhibitors" and "bone formation accelerators," the former hindering bone resorption by osteoclasts and the latter increasing bone formation by osteoblasts. Currently, bisphosphonates, which are bone resorption inhibitors drugs, are more commonly used clinically than others. Using the signaling pathway or implantation bone marrow stem cell provides a novel direction for the treatment of OP, especially OP after transplantation. This review addresses the mechanism of OP and its correlation with organ transplantation, lists prevention and management of bone loss in the transplant recipient, and discusses the recipients of different age and gender.

Comparison of surgical techniques of 111 medial malleolar fractures classified by fracture geometry

BACKGROUND

Evaluation of operative techniques used for medial malleolar fractures by classifying fracture geometry has not been well documented.

METHODS

One hundred eleven patients with medial malleolar fractures (transverse n = 63, oblique n = 29, vertical n = 7, comminuted n = 12) were included in this study. Seventy-two patients had complicating comorbidities. All patients were treated with buttress plate, lag screw, tension band, or K-wire fixation. Treatment outcomes were evaluated on the basis of radiological outcome (union, malunion, delayed union, or nonunion), need for operative revision, presence of postoperative complications, and AOFAS Ankle-Hindfoot score.

RESULTS

For transverse fractures, tension band fixation showed the highest rate of union (79%), highest average AOFAS score (86), lowest revision rate (5%), and lowest complication rate (16%). For oblique fractures, lag screws showed the highest rate of union (71%), highest average AOFAS score (80), lowest revision rate (19%), and lowest complication rate (33%) of the commonly used fixation techniques. For vertical fractures, buttress plating was used in every case but 1, achieving union (whether normal or delayed) in all cases with an average AOFAS score of 84, no revisions, and a 17% complication rate. Comminuted fractures had relatively poor outcomes regardless of fixation method.

CONCLUSIONS

The results of this study suggest that both tension bands and lag screws result in similar rates of union for transverse fractures of the medial malleolus, but that tension band constructs are associated with less need for revision surgery and fewer complications. In addition, our data demonstrate that oblique fractures were most effectively treated with lag screws and that vertical fractures attained superior outcomes with buttress plating.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Operative treatment of nonunion following distal fibula and medial malleolar ankle fractures

BACKGROUND

The purpose of this study was to evaluate the outcomes following operative treatment of nonunited rotational distal fibula and medial malleolar ankle fractures.

METHODS

Seventeen patients were identified as having a nonunion of a rotational ankle fracture. All patients were evaluated clinically, radiographically, and functionally with the Short Musculoskeletal Functional Assessment (SMFA) questionnaire. They were divided into lateral and medial malleolus groups and compared with 44 patients following a nonoperative (SE2/3) ankle fracture and 25 patients who underwent operative fixation of their SE4 ankle fracture for functional comparison.

RESULTS

Two of the 17 patients were excluded. The patients in the medial malleolar group were notably older than those in the other groups. Nonunions included 12 distal fibulas and 3 medial malleoli. All patients were treated with open reduction with plate and screw fixation or screw fixation alone. Adjunctive grafting was performed in all but 2 cases. The average time to healing was 5.2 months post surgery. At latest follow-up, mean 33.9 months, all nonunions had resolved. Standardized SMFA scores differed notably among the groups in the Bothersome, Emotional, and Mobility categories. There was no difference between lateral malleolar nonunion patients and surgically treated SE4 patients.

CONCLUSIONS

Reports of nonunions of fractures of lateral and medial malleoli have been rarely reported. Operative treatment of these nonunions in this study led to reliable bony healing. Patients who underwent surgery for these nonunions ultimately had similar outcomes and range of motion compared with patients who underwent operative treatment for acute ankle fractures.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

A biomechanical investigation of a knotless tension band in medial malleolar fracture models in composite Sawbones®

The present study introduces a knotless tension band construct and compares its biomechanical behavior with that of a traditional stainless steel tension band construct. Fourth-generation composite tibial Sawbones(®) were used in the present study. Fracture models were created to mimic Orthopaedic Trauma Association type 44-B2.2 ankle fractures. A total of 20 specimens were randomized evenly into a stainless steel tension band group (control group); or a knotless tension band group. The fixation constructs were mechanically tested, and the stiffness and failure strengths were calculated. Two failure strengths were determined: the engineering-based failure strength, defined as the greatest tensile load tolerated by the construct; and the clinical failure strength, defined as the force required to displace the fracture by 2 mm. We used 2-tailed independent samples t tests to compare and identify significant differences. The knotless tension band construct was 7.7% stronger and 33.2% stiffer and required a 36.7% greater force to displace the fracture by 2 mm. Independent sample t tests confirmed that differences in mean stiffness (p = .003) and clinical failure strength (p = .003) were statistically significant. Although the mean engineering strength for the knotless group was greater than that for the stainless steel group, this difference was not statistically significant (p = .170). This knotless tension band construct could potentially offer both clinical and biomechanical advantages compared with the current stainless steel standard.