Abstract
Cartilage damage or mechanical blocking from screw penetration into intra-articular cartilage can reduce the chances of successful outcomes during medial malleolus fixation. There have been diverging opinions among surgeons concerning the reliability of radiographic assessment of fracture fixation and malleolus screw positioning. Therefore, this radiographic study examines the location of medial malleolus lag screws relative to the ankle mortise articular surface. In three Sawbones models, Kirschner wires were overdrilled with a 4.0-mm cannulated cortical screw simulating screws that would be intra- and extra-articular when performing open reduction and internal fixation of a medial malleolar fracture. Under fluoroscopy, images were evaluated to determine whether known intra-articular screws appeared extra-articular in any radiographic view. No image from models with known intra-articular penetration appeared extra-articular in any view or under “live” fluoroscopy. At 20° internal rotation, a screw with a known extra-articular position appeared to be within the cartilage. Intra-operative fluoroscopy is necessary to ensure proper extra-articular placement of screws. If a screw is pictured extra-articular in any radiograph, then it can be assumed that the screw is indeed out of the joint.
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Giordano V, Gomes AFS, Amaral NP, Albuquerque RP, Pires RES (2011) Preventing surgical complications: a survey on surgeons’ perception of intra-articular malleolar screw misplacement in a cadaveric study. Patient Saf Surg 5:24
Goergen TG, Danzig LA, Resnick D, Owen CA (1977) Roentgenographic evaluation of the tibiotalar joint. J Bone Joint Surg Am 59:874–877
Pankovich AM (1991) Trauma to the ankle. In: Jahss MH (ed) Disorders of the foot and ankle: medical and surgical management, 2nd edn. W.B Saunders, Philadelphia, pp 2361–2414
Shelton ML (1994) Complications of fractures and dislocations of the ankle. In: Epps CH Jr (ed) Complications in orthopaedic surgery, vol 2, 3rd edn. J.B Lippincott, Philadelphia, pp 595–648
Gourineni KV, Knuth AE, Nuber GF (1999) Radiographic evaluation of the position of implants in the medial malleolus in relation to the ankle joint space: anteroposterior compared with mortise radiographs. J Bone Joint Surg Am 81:364–369
Geissler WB, Tsao AK, Hughes JL (1996) Fractures and injuries of the ankle. Rockwood and green’s fractures in adults, 4th edn. Lippincott-Raven, Philadelphia, pp 2201–2261
Michelson JD, Hamel AJ, Buczek FL, Sharkey NA (2002) Kinematic behavior of the ankle following malleolar fracture repair in a high-fidelity cadaver model. J Bone Joint Surg Am 84:2029–2038
Romiti SL, Leitschuh PC (2001) Hardware in the medial malleolus: is it intra-articular? Foot Ankle Int 22:905–907
Cole P, Levy B, Schatzker J, Watson JT (2009) Tibial plateau fractures. In: Browner B, Levine A, Jupiter J, Trafton P, Krettek C (eds) Skeletal trauma: basic science management and reconstruction, 4th edn. Elsevier, Philadelphia, pp 2201–2287
Tweet ML, Calfee RP, Stern PJ (2010) Rotational fluoroscopy assists in detection of intra-articular screw penetration during volar plating of the distal radius. J Hand Surg Am 35:619–627
Soong M, Got C, Katarincic Akelman E (2008) Fluoroscopic evaluation of intra-articular screw placement during locked volar plating of the distal radius: a cadaveric study. J Hand Surg Am 33:1720–1723
Beris AE, Kabbani KT, Xenakis TA, Mitsionis G, Soucacos PK, Soucacos PN (1997) Surgical treatment of malleolar fractures. A review of 144 patients. Clin Orthop Relat Res 341:90–98
Roberts RS (1983) Surgical treatment of displaced ankle fractures. Clin Orthop Relat Res 172:164–170
Ricci WM, Tornetta P, Borrelli J Jr (2012) Lag screw fixation of medial malleolar fractures: a biomechanical, radiographic, and clinical comparison of unicortical partially threaded lag screws and bicortical fully threaded lag screws. J Orthop Trauma 26:602–606
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
Femino JE, Gruber BF, Karunakar MA (2007) Safe zone for the placement of medial malleolar screws. J Bone Joint Surg Am 89:133–138
Berkes MB, Little MTM, Lazaro LE et al (2013) Articular congruity is associated with short-term clinical outcomes of operatively treated SER IV ankle fractures. J Bone Joint Surg Am 95:1769–1775
van Bergen CJA, Tuijhof GJM, Sierevelt IN, van Dijk CN (2011) Direction of the oblique medial malleolar osteotomy for exposure of the talus. Arch Orthop Trauma Surg 131:893–901
Kang K, Chen Y, Qiang M, Hao Y, Li H, Dai H (2014) The morphology of medial malleolus and its clinical relevance. Pak J Med Sci 30:348–351
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Dr. Wera has nothing to disclose. Dr. Seligson reports Grants from Fischer-Owen Orthopaedic Trust fund, during the conduct of the study; personal fees from University of Louisville Department of Orthopaedic Surgery, personal fees from Stryker, personal fees from Books, outside the submitted work. Dr. Riehl has nothing to disclose.
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Wera, J.C., Seligson, D. & Riehl, J.T. Medial malleolus screws: out in one view and out. Eur J Orthop Surg Traumatol 25, 1189–1193 (2015). https://doi.org/10.1007/s00590-015-1673-7
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DOI: https://doi.org/10.1007/s00590-015-1673-7