SLR - March 2023 - Brandon Kelemen, DPM
Title: Medial Malleolar Fracture Management- A Comparative Study of Radiological Outcome Between Open Reduction Internal Fixation and Closed Reduction Percutaneous FixationReference: Ethiraj P, Venkataraman S, Heddur Shanthappa A, Agrawal S. Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research (SDUAHER) University, Kolar, Karnataka, India
Level of Evidence: III
Reviewed By: Brandon Kelemen, DPM
Residency Program: St. Elizabeth’s Medical Center, Boston, MA
Podiatric Relevance: There is much debate in regard to various treatments to address medial malleolar fractures. If addressed surgically, this is done via open reduction with internal fixation (ORIF) or percutaneous reduction with internal fixation. Historically, these fractures have been treated with ORIF. In recent literature, percutaneous fixation has been gaining interest due to minimal soft tissue involvement and minimizing chance of infection. This study reviewed 67 ankle fractures and included both isolated medial malleolar and bimalleolar equivalent fractures from a single institution. Additionally, it compared the radiographic results in addition to post-operative return to weight bearing for ORIF and percutaneous internal fixation.
Methods: A level III retrospective cohort study was performed for all patients who received ORIF and percutaneous internal fixation for medial malleolar osteotomies at a tertiary referred hospital. A total of 67 consecutive ankle fractures met the inclusion criteria and were divided into the two groups (52 in ORIF, 15 in closed reduction percutaneous fixation). Partial weight bearing with assistance of walker support and ankle mobilization started after 6 weeks. Full weight bearing was started at the end of 3 months. Primary outcomes were evaluated at 1st month, 2nd month, 3rd month, 6th month, and 1 year. They evaluated patient clinical functionality, time to radiological union of fractures, and associated complications.
Results: Clinical outcome among groups, in which excellent results were seen in (84.6% of patients in Group 1 and 73.3% in Group 2, was not statistically significant. Average union time in Group 1 and group 2 was 13 weeks and 16 weeks respectively, which was statistically significant.
Conclusions: There were statistically significant differences found in average fracture union time between the two groups. This was also seen in a similar article such as Weinraub et al 2017 where they noted that there was a common occurrence of soft tissue interposition in 93.3% of the ORIF group. This may have played a role in delay of unionization of the fracture site seen at post-operative visits. There were a number of limitations given the nature of the retrospective comparison study design, including, but not limited to, concerns for selection bias into surgical groups. In addition, since there were heterogeneous groups, functional outcome was not comparable between two groups. Therefore, comparison was evaluated via radiological product.