SLR - October 2020 - Taylor R. Tendrich

Arthroscopy Assisted Reduction in the Management of Isolated Medial Malleolar Fracture

Reference: Chao Liu, M.D., Ph.D., Jia-Xing You, M.Sc., Jie Yang, M.Sc., Hai-Feng Zhu, M.Sc., He-Jun Yu, M.D., Shun-Wu Fan, M.D., and Hong-Ye Li, M.D. (2020). Arthroscopy Assisted Reduction in the Management of Isolated Medial Malleolar Fracture. Journal of Arthroscopic and Related Surgery, 36(6), 1714-1721.

Scientific Literature Review 

Reviewed By: Taylor R. Tendrich, DPM 
Residency Program: Northwest Medical Center – Margate, FL 

Podiatric Relevance: Acute ankle fractures represent the fourth most common musculoskeletal injuries, with the incidence of these injuries being 187 per 100,000. Fractures of the medial malleolus account for 50 percent of all ankle fractures and can occur in isolation, bi-malleolar or tri-malleolar fracture patterns. Currently there is no consensus regarding the treatment for isolated medial malleolar fractures. Intra-articular pathologies are difficult to diagnose leading to poor treatment outcomes. Ankle arthroscopy has the potential to identify these intra-articular lesions through improved visualization of articular components and can assess joint congruity after open reduction internal fixation. The purpose of this study was to compare arthroscopic reduction percutaneous fixation in isolated medial malleolar ankle fractures to conventional open reduction internal fixation in medial malleolar ankle fractures.  

Methods: A prospective study was performed between 2011 and 2016, 77 total patients. The arthroscopic percutaneous group consisted of 34 patients and the ORIF group consisted of 43 patients. The inclusion criteria was: isolated medial malleolar fractures within one week, fracture displacement of greater than 2mm, and all patients greater than 18 years of age. The fractures were classified according to the Herscocvici classification, and types A (avulsion at the tip) and D (vertical medial malleolar fracture) were excluded. The arthroscopic percutaneous technique consisted of using standard anteromedial and anterolateral approaches with a 4.0 millimeters, 30 degree scope. A 1.5 millimeters hole was drilled into distal fragment and a point to point reduction clamp with one arm in the anteromedial incision was used. Once reduction was confirmed arthroscopically, fixation was placed with two 3.5 or 4.5 millimeters cannulated screws. The ORIF technique consisted of two 3.5 millimeter or 4.5 millimeter cannulated screws placed about the fracture site. Both groups received the same post-operative protocol and the outcomes were measured based on the OMAS score, VAS scale, ankle joint ROM, radiographic evaluation for union and osteoarthritis and for complications. 

Results: The percutaneous and ORIF group were similar in many of the baseline characteristics. The mean follow-up was five years for both groups. The mean OMAS score was higher in the arthroscopic group than ORIF group (statistically significant at six months and one year). During the short-term follow-up period (i.e. at six months and one year), ankle ROM was markedly improved in the arthroscopic percutaneous group, unlike in the ORIF group. The VAS scale was only significantly different at three days and two weeks. Finally, fracture union was achieved in all patients. 

Conclusions: The authors revealed that arthroscopy assisted reduction in isolated medial malleolar fractures is a feasible alternative to conventional ORIF. Arthroscopy has excellent short-term outcomes and has been proven to be important in managing ankle pathology. This is important in podiatric surgery because it allows for an alternative method to treating medial malleolar ankle fractures through minimal incisions which can be beneficial to specific patient populations. That being said, arthroscopy should be considered to aid in reduction of malleolar fractures due to the positive outcomes. 

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