SLR - November 2018 - Greg S. Lifferth

A Comparative Study of Three Commonly Used Fixation Techniques for Isolated Medial Malleolus Fracture

Reference: Kochai, A., Turker, M., Cicekli, O, Ozdemir, U., Bayram, L., Erkorkmaz U., Sukur, E., A Comparative Study of Three Commonly Used Fixation Techniques for Isolated Medial Malleolus Fracture. Joint Diseases and Related Surgery (Elkem Hast Cerrahisi) 2018 Aug; 29: 104–9.

Scientific Literature Review

Reviewed By: Greg S. Lifferth, DPM
Residency Program: Maricopa Medical Center, Phoenix, AZ

Podiatric Relevance: Medial malleolus fractures are commonly seen and treated by foot and ankle specialists. Various methods of surgical correction have been discussed in the literature for open reduction internal fixation involving compression plates, screw fixation or the use of tension wiring. This article compares three modes of fixation involving tension wiring, partially threaded cannulated screws and fully threaded cannulated headless screws by looking at the factors and outcomes, such as time to union and implant complications.

Methods: This article was a retrospective comparative study of three groups consisting of 92 patients who underwent open reduction internal fixation for medial malleolar fractures. Of the 92 patients included in the study, 26 underwent fixation with tension wiring, 32 underwent fixation with partially threaded screws and 32 underwent compression with fully threaded headless screws. Patients were nonweightbearing for four weeks and transitioned to partial weightbearing until 10 weeks. Radiographs were utilized to assess union rates and AOFAS score assessed successful outcomes and patient satisfaction postoperatively.

Results: In comparing the three groups, patients who underwent correction with the headless fully threaded screw had no implant failure or irritation and union rates noted at median average of nine weeks. In contrast, Groups A and B that underwent fixation with tension wiring and partially threaded screws achieved union at 10 weeks and 12 weeks. Additionally, Group A reported two patients with implant migration and six patients undergoing hardware removal due to implant irritation. Group B reported one patient with hardware loosening and 10 patients undergoing hardware removal due to pain and irritation from the hardware. Group C reported no hardware failures or postop irritation. Patients in Groups A and B were found to have a lower BMI and were at an increased risk of hardware failure and irritation with a p-value < 0.001.   

Conclusion: This article, although a retrospective study, adds clinical relevance in deciding which method of fixation to use when surgically correcting closed medial malleolar fractures. Surgeons should evaluate patients' soft-tissue envelope and consider BMI as it relates to postop hardware irritation. Although all three fixation methods provided successful healing of fractures, headless fully threaded cannulated screws will lead to faster union rates and decreased hardware irritation. 

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