Bicortical Fixation of Medial Malleolar Fractures: A Review of 23 Cases at Risk for Complicated Bone Healing

Foot and Ankle Residency Program, Kaiser San Francisco Bay Area, Oakland, CA 94801, USA.
The Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons (Impact Factor: 0.85). 01/2012; 51(1):39-44. DOI: 10.1053/j.jfas.2011.09.007
Source: PubMed


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: Malleolar fractures rank among the most frequent skeletal injuries. The majority of orthopaedic and trauma surgeons incline to surgical therapy with anatomical reposition and retention going for absolute stability. Recommended surgical techniques with screws, plates or tension-band wiring usually presents no problems for surgeons. Unsatisfactory postoperative radiological results, however, are often tolerated because revision surgery may not always have expected results. Difficulties in decision-making for right treatment are (a) the classification and right interpretation of the fracture type, (b) the question of stability and right treatment of syndesmotic injury, (c) the reconstruction of the distal fibula in length and without malrotation, (d) the question of surgical stabilization of the posterior tibial edge, and (e) the diagnostic and therapeutic approach to the medial osteoligamenteous complex. It is necessary to realise that, whatever classification has been used, injury proceeds in connected stages and can stop in each stage (Lauge-Hansen). Both supination and pronation osteoligamenteous injuries have specific patterns. It is important to analyse these patterns and put right therapeutic consequences. Included in this analysis must be the question of the right management of syndesmotic injury. It needs attention for exact reposition and retention of the distal fibula. Also, a fracture analysis of the medial complex is very important for right osteosynthesis following the principles in fracture treatment. In fractures of the anterior colliculus of the medial malleolus, the deep part of deltoid ligament can also be injured. The listed problems with their critical analyses and interpretations show that injuries of the ankle joint can be difficult to diagnose and treat. In conclusion references to these problems are critically interpreted.
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