Bicortical Fixation of Medial Malleolar Fractures: A Review of 23 Cases at Risk for Complicated Bone Healing
ABSTRACT Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications.
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ABSTRACT: The present study introduces a knotless tension band construct and compares its biomechanical behavior with that of a traditional stainless steel tension band construct. Fourth-generation composite tibial Sawbones(®) were used in the present study. Fracture models were created to mimic Orthopaedic Trauma Association type 44-B2.2 ankle fractures. A total of 20 specimens were randomized evenly into a stainless steel tension band group (control group); or a knotless tension band group. The fixation constructs were mechanically tested, and the stiffness and failure strengths were calculated. Two failure strengths were determined: the engineering-based failure strength, defined as the greatest tensile load tolerated by the construct; and the clinical failure strength, defined as the force required to displace the fracture by 2 mm. We used 2-tailed independent samples t tests to compare and identify significant differences. The knotless tension band construct was 7.7% stronger and 33.2% stiffer and required a 36.7% greater force to displace the fracture by 2 mm. Independent sample t tests confirmed that differences in mean stiffness (p = .003) and clinical failure strength (p = .003) were statistically significant. Although the mean engineering strength for the knotless group was greater than that for the stainless steel group, this difference was not statistically significant (p = .170). This knotless tension band construct could potentially offer both clinical and biomechanical advantages compared with the current stainless steel standard.The Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons 12/2012; 52(2). DOI:10.1053/j.jfas.2012.11.001 · 0.98 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate the outcomes following operative treatment of nonunited rotational distal fibula and medial malleolar ankle fractures. Seventeen patients were identified as having a nonunion of a rotational ankle fracture. All patients were evaluated clinically, radiographically, and functionally with the Short Musculoskeletal Functional Assessment (SMFA) questionnaire. They were divided into lateral and medial malleolus groups and compared with 44 patients following a nonoperative (SE2/3) ankle fracture and 25 patients who underwent operative fixation of their SE4 ankle fracture for functional comparison. Two of the 17 patients were excluded. The patients in the medial malleolar group were notably older than those in the other groups. Nonunions included 12 distal fibulas and 3 medial malleoli. All patients were treated with open reduction with plate and screw fixation or screw fixation alone. Adjunctive grafting was performed in all but 2 cases. The average time to healing was 5.2 months post surgery. At latest follow-up, mean 33.9 months, all nonunions had resolved. Standardized SMFA scores differed notably among the groups in the Bothersome, Emotional, and Mobility categories. There was no difference between lateral malleolar nonunion patients and surgically treated SE4 patients. Reports of nonunions of fractures of lateral and medial malleoli have been rarely reported. Operative treatment of these nonunions in this study led to reliable bony healing. Patients who underwent surgery for these nonunions ultimately had similar outcomes and range of motion compared with patients who underwent operative treatment for acute ankle fractures. Level of Evidence: Level III, retrospective comparative series.Foot & Ankle International 03/2013; 34(3):365-71. DOI:10.1177/1071100712473740 · 1.63 Impact Factor
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ABSTRACT: Displaced medial malleolus fractures require surgical repair because of the critical role the structure plays in normal joint function. Various approaches exist, but options are limited for small fragment fractures. This study compared repair with the Medial Malleolar Sled fixation system (Trimed, Inc, Valencia, CA) to lag screws in 2 modes of biomechanical loading in a cadaveric model. A Müller type B medial malleolus fracture was simulated on matched pairs of cadaveric lower extremities and repaired with the sled or 2 cancellous lag screws. Tibial distraction (tension, n = 10) or internal rotation (torsion, n = 11) was applied. Fragment movement was measured in the sagittal (tension and torsion) and transverse (torsion-only) planes. Fragment movement at 1 mm and 2 mm (clinical malunion) of gapping during tension and at 2, 4, 6, and 8 N-m during torsion was analyzed via paired t tests. In tension, the load at the 2-mm gap was statistically lower for screws (P = .026). Opening angle was statistically larger for the sled at the 1-mm (P = .0004) and 2-mm (P = .008) gap. In torsion, gapping was statistically lower for the sled (ranging from P = .0013 at 4 N-m to P = .0187 at 8 N-m). No differences were detected for opening angle or transverse plane movement. The sled appeared stronger in tension and as effective as lag screws in torsion. The sled may be a viable option for fractures too small for 4.0- or 3.5-mm lag screws. The sled may be suitable in applications where a tension band would normally be considered and may provide stronger fixation in osteoporotic bone compared with lag screw fixation.Foot & Ankle International 03/2013; 34(3):426-33. DOI:10.1177/1071100712466231 · 1.63 Impact Factor