SLR - July 2019 - Parth J. Bhakta

Selective Fixation of the Medial Malleolus in Unstable Ankle Fractures

Reference: Carter T, Mackenzie S, Bell K, Hollyer M, Gill E, MacDonald D, Duckworth A, White T. Selective Fixation of the Medial Malleolus in Unstable Ankle Fractures. Injury: International J of the Care of the Injured. 2019 Mar 9; pp 983-989.

Scientific Literature Review

Reviewed By: Parth J. Bhakta, DPM
Residency Program: Hunt Regional Medical Center – Greenville, TX

Podiatric Relevance: When it comes to unstable ankle fractures the role of the lateral malleolus is understood in that it plays a major role in controlling anatomical reduction of the talus. What we do not completely know is the importance of the medial malleolus. Although there are significant complications associated with medial sided injuries such as infection and damage to local structures, the significance of fixing the medial malleolus is still not quite clear. The aim of this study is to compare the outcomes of patients with either bimalleolar and trimalleolar ankle fractures who underwent stabilization of the fibula with a nail with or without medial malleolar fixation.

Methods: This is a retrospective analysis of a prospective randomized controlled trial of data collected from 2008 to 2016 of 247 patients over the age of 16 who underwent fibular nail stabilization of an unstable ankle fracture. Patients that sustained an isolated fibular fracture or had a purely ligamentous medial component were excluded. The outcomes were evaluated using the Olerud-Molander Ankle Score, EuroQol-5D, and the Manchester-Oxford Foot Questionnaire.

Results: The study showed that there was no significant difference between the patients that had their medial malleolus fixed versus those who did not with respect to failure of fixation/loss of reduction of the talus. Medial malleolar fixation was performed on 193 patients by either tension band wiring or 3.5 mm partially threaded cancellous screws. At a mid-term follow up of a mean 4.8 years there was no significant difference between the two groups with respect to the median OMAS (85 non-fixation vs 80 fixation) or the median EQ-5d (0.80 non-fixation vs 0.81 fixation). Medial sided complication occurred in 16% of the fixation group, of whom 10% needed further surgery.

Conclusions: As stated in the article, there is no statistically significant difference when comparing operative vs nonoperative care of the medial malleolus when dealing with unstable ankle fractures that are stabilized by a fibular nail. This study provided an alternative approach when it comes to addressing the medial malleolus in that it may be best to leave it alone as to avoid associated complications. As seen in this study there were complications associated with operative treatment of the medial malleolus. More research on different lateral malleolar fixation approaches may benefit future decision-making as not every fibular fracture is amenable to a nail. There are some limitations in this study, one being that there is a lack of objective outcome measurements such as ankle joint range of motion. Although there was no statistically significant difference between the two groups, any difference that was present (VAS health, VAS pain, or the return to work satisfaction) pointed in favor of the nonoperative group. 

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