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Is fixation of the medial malleolus necessary in unstable ankle fractures?

  • Orthopaedic Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

It is unclear whether the medial malleolus in unstable bi- and tri- malleolar ankle fractures without medial talar displacement should be addressed surgically. This study reviews a fixation protocol for the medial malleolar component of unstable bi- or tri- malleolar ankle fractures.

Materials and methods

Two hundred fifty-seven patients who sustained bi- (AO/OTA 44-B2) or tri- (AO/OTA 44-B3) malleolar ankle fractures between January 2005 and August 2019 at two Level 1 trauma centers were retrospectively identified. Medial malleolar fractures were defined as anterior, supra or intercollicular fractures based on the exit of the posterior fracture line. Fixation of the medial malleolar component was performed based on surgical algorithm. Only large or significantly displaced medial malleolar fractures were fixed if the soft tissues were amenable. Primary outcome measure was the presence of medial-sided ankle pain after operative or non-operative treatment of the medial malleolar fracture after a minimum follow up of 6 months. Presence of pain was defined by a pain score of 3 or higher on a 10-point VAS pain score at the site of the medial malleolar fracture.

Results

Significantly more patients in the supracollicular group reported the presence of pain when this type was not fixed versus fixed (28 vs 14%, p = 0.0094). Significantly more patients in the anterior collicular subgroup reported the presence of pain when this type was fixed versus not fixed (40 vs 10%, p = 0.0438). There was no difference in the number of patients reporting pain in the intercollicular group when comparing those who were fixed versus not fixed, (21 vs 22%, p = 1.000).

Conclusions

When examining post-operative pain, not all medial malleolar fractures require fixation when appropriately selected based on fracture pattern. Only 10% of patients with anterior collicular fractures reported pain after non operative management. Unsurprisingly, more patients in the supracollicular fractures reported pain without surgery compared to with surgery. Fracture pattern should be considered in the treatment algorithm for the medial malleolar component in bi- and tri- malleolar fractures.

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References

  1. Sneppen O (1969) Long-term course in 119 cases of pseudarthrosis of the medial malleolus. Acta Orthop Scand 40(6):807–816

    Article  CAS  PubMed  Google Scholar 

  2. Svend-Hansen H, Bremerskov V (1978) Ankle fractures treated by fixation of the medial malleolus alone: late results in 29 patients. Acta Orthop Scand 49(2):211–214

    Article  CAS  PubMed  Google Scholar 

  3. Phillips WA, Schwartz HS, Keller CS et al (1985) A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg Am 67(1):67–78

    Article  CAS  PubMed  Google Scholar 

  4. de Souza LJ, Gustilo RB, Meyer TJ (1985) Results of operative treatment of displaced external rotation-abduction fractures of the ankle. J Bone Joint Surg Am 67(7):1066–1074

    Article  PubMed  Google Scholar 

  5. Wei SY, Okereke E, Winiarsky R et al (1999) Nonoperatively treated displaced bimalleolar and trimalleolar fractures: a 20-year follow-up. Foot Ankle Int 20(7):404–407

    Article  CAS  PubMed  Google Scholar 

  6. Makwana NK, Bhowal B, Harper WM et al (2001) Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age a prospective, randomised study. J Bone Joint Surg Br 83(4):525–529

    Article  CAS  PubMed  Google Scholar 

  7. Clements J, Motley T, Garrett A et al (2008) Nonoperative treatment of bimalleolar equivalent ankle fractures: a retrospective review of 51 patients. J Foot Ankle Surg 47(1):40–45

    Article  PubMed  Google Scholar 

  8. Stufkens SAS, Knupp M, Lampert C et al (2009) Long-term outcome after supination-external rotation type-4 fractures of the ankle. J Bone Joint Surg Br 91(12):1607–1611

    Article  CAS  PubMed  Google Scholar 

  9. Gougoulias N, Khanna A, Sakellariou A et al (2010) Supination-external rotation ankle fractures: stability a key issue. Clin Orthop Relat Res 468(1):243–251

    Article  PubMed  Google Scholar 

  10. Lauge-Hansen N (1950) Fractures of the ankle II combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 60(5):957–985

    Article  CAS  Google Scholar 

  11. Lloyd J, Elsayed S, Hariharan K et al (2006) Revisiting the concept of talar shift in ankle fractures. Foot Ankle Int 27:793–796

    Article  PubMed  Google Scholar 

  12. Lampridis V, Gougoulias N, Sakellariou A (2018) Stability in ankle fractures: diagnosis and treatment. EFORT Open Rev 3(5):294–303. https://doi.org/10.1302/2058-5241.3.170057

    Article  PubMed  PubMed Central  Google Scholar 

  13. Meinberg EG, Agel J, Roberts CS et al (2018) Fracture and dislocation classification compendium-2018. J Orthop Trauma 32(Supplement 1):S1–S170

    Article  PubMed  Google Scholar 

  14. Lee JS, Hobden E, Stiell IG, Wells GA (2003) Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med 10(10):1128–1130. https://doi.org/10.1111/j.1553-2712.2003.tb00586.x

    Article  PubMed  Google Scholar 

  15. Michelsen JD, Ahn UM, Helgemo SL (1996) Motion of the ankle in a simulated supination-external rotation fracture model. J Bone Joint Surg Am 78(7):1024–1031

    Article  CAS  PubMed  Google Scholar 

  16. Herscovici D, Scaduto JM, Infante A (2007) Conservative treatment of isolated fractures of the medial malleolus. J Bone Joint Surg Br 89(1):89–93

    Article  PubMed  Google Scholar 

  17. Lindenbaum BL (1983) Loss of the medial malleolus in a bimalleolar fracture a case report. J Bone Joint Surg Am 65(8):1184–1185

    Article  CAS  PubMed  Google Scholar 

  18. Hernigou P, Goutallier D (1991) Absence of the medial malleolus a case report with a 20-year follow-up study. Clin Orthop Relat Res 267:141–142

    Article  Google Scholar 

  19. Pankovich AM, Shivaram MS (1979) Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament. I Acta Orthop Scand 50(2):217–223

    Article  CAS  PubMed  Google Scholar 

  20. Pankovich AM, Shivaram MS (1979) Anatomical basis of variability in injuries of the medial malleolus and the deltoid ligament II. Acta Orthop Scand 50(2):225–236

    Article  CAS  PubMed  Google Scholar 

  21. Tornetta P (2000) Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am 82(6):843–848

    Article  PubMed  Google Scholar 

  22. Tejwani NC, McLaurin TM, Walsh M et al (2007) Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury? J Bone Joint Surg Am 89(7):1438–1441

    Article  PubMed  Google Scholar 

  23. Michelson JD, Magid D, McHale K (2007) Clinical utility of a stability-based ankle fracture classification system. J Orthop Trauma 21(5):307–315

    Article  PubMed  Google Scholar 

  24. Carter TH, Mackenzie SP, Bell KR et al (2019) Selective fixation of the medial malleolus in unstable ankle fractures. Injury 50(4):983–989. https://doi.org/10.1016/j.injury.2019.03.010

    Article  PubMed  Google Scholar 

  25. Hoelsbrekken SE, Kaul-Jensen K, Morch T et al (2013) Nonoperative treatment of the medial malleolus in bimalleolar and trimalleolar ankle fractures: a randomized controlled trial. J Orthop Trauma 27:633–637

    Article  PubMed  Google Scholar 

  26. Carter TH, Oliver WM, Graham C et al (2019) 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. Trials 20:565. https://doi.org/10.1186/s13063-019-3642-7

    Article  PubMed  PubMed Central  Google Scholar 

  27. Carter TH, Duckworth AD, White TO (2019) Medial malleolar fractures. Bone Joint J 101-B(5):512–521. https://doi.org/10.1302/0301-620x.101b5.bjj-2019-0070

    Article  CAS  PubMed  Google Scholar 

  28. Swart EF, Vosseller JT (2014) Arthroscopic assessment of medial malleolar reduction. Arch Orthop Trauma Surg 134:1287–1292

    Article  PubMed  Google Scholar 

  29. Brown OL, Dirschl DR, Obremskey WT (2001) Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma 15:271–274

    Article  CAS  PubMed  Google Scholar 

  30. Tornetta P 3rd, Qadir R, Sanders R. Pain dominates summed scores for hindfoot and ankle trauma. J Orthop Trauma. 2013 Aug;27(8):477–482. https://doi.org/10.1097/BOT.0b013e31827973b3. PMID: 23114415.

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No funding was needed for the completion of this study.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University Medical School, 800 Washington Street, Box 300, Boston, MA, 02116, USA

    John M. Pinski & Scott P. Ryan

  2. Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

    Jason L. Pittman

  3. Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, MA, USA

    Paul Tornetta

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  1. John M. Pinski
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  2. Scott P. Ryan
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Correspondence to John M. Pinski.

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Approval for this study was granted by both institutional review boards.

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Pinski, J.M., Ryan, S.P., Pittman, J.L. et al. Is fixation of the medial malleolus necessary in unstable ankle fractures?. Arch Orthop Trauma Surg 143, 2999–3005 (2023). https://doi.org/10.1007/s00402-022-04528-9

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  • DOI: https://doi.org/10.1007/s00402-022-04528-9

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