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

ArticleinThe Journal of foot and ankle surgery: official publication of the American College of Foot and Ankle Surgeons 51(1):39-44 · January 2012with11 Reads
DOI: 10.1053/j.jfas.2011.09.007 · Source: PubMed
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.
    • "The techniques range from hook plating, 3.5 mm bicortical screws for patients with concerning bone quality and standard 4.0 mm cancellous or cannulated screws for larger fragment sizes for medial malleolus fractures. The tension band wiring with a stainless steel system has been documented as offering superior strength and stiffness compared to screw fixation with a common goal of healing the fracture in a timely manner without associated risks [2,[6][7][8][9]. Even with superior results for medial malleolus fixation, Fowler et al. relate that the thin overlying skin, the anatomical location, and the soft tissue irritation appear to be reasons to avoid this approach [10]. "
    [Show abstract] [Hide abstract] ABSTRACT: The traditional stainless steel wire tension band (WTB) has been popularized for small avulsion fractures at the medial malleolus. Despite the tension band principle creating a stable construct, complications continue to arise utilizing the traditional stainless steel WTB with patients experiencing hardware irritation at the tension band site and subsequent hardware removal. Coupled with hardware irritation is fatigue failure with the wire. The goal of this investigation was to retrospectively compare this traditional wire technique to an innovative knotless tension band (KTB) technique in order to decrease costly complications. A total of 107 patients were reviewed with a minimum follow-up of 1 year. Outcome measures include descriptive data, fracture classification, results through economic costs, and fixation results (including hardware status, healing status, pain status, and time to healing). The KTB group had a 13% lower true cost as compared to the WTB group while the fixation results were equivocal for the measured outcomes. Our results demonstrate that the innovative KTB is comparable to the traditional WTB while offering a lower true cost, an irritation free reduction all without the frustration of returning to the operating room for additional hardware removal, which averages approximately to $8,288.
    Full-text · Article · May 2016
    • "Older transplant recipients had worse outcomes than younger recipients [87]. OP is a major concern during the whole life of transplant recipients [88]. So, the management of elderly recipients should be rigorously handled. "
    [Show abstract] [Hide abstract] ABSTRACT: Osteoporosis (OP) has emerged as a frequent and devastating complication of organ solid transplantation process. Bone loss after organ transplant is related to adverse effects of immunosuppressants on bone remodeling and bone quality. Many factors contribute to the pathogenesis of OP in transplanted patients. Many mechanisms of OP have been deeply approached. Drugs for OP can be generally divided into "bone resorption inhibitors" and "bone formation accelerators," the former hindering bone resorption by osteoclasts and the latter increasing bone formation by osteoblasts. Currently, bisphosphonates, which are bone resorption inhibitors drugs, are more commonly used clinically than others. Using the signaling pathway or implantation bone marrow stem cell provides a novel direction for the treatment of OP, especially OP after transplantation. This review addresses the mechanism of OP and its correlation with organ transplantation, lists prevention and management of bone loss in the transplant recipient, and discusses the recipients of different age and gender.
    Full-text · Article · Aug 2015
    • "The techniques range from hook plating, 3.5 mm bicortical screws for patients with concerning bone quality and standard 4.0 mm cancellous or cannulated screws for larger fragment sizes for medial malleolus fractures. The tension band wiring with a stainless steel system has been documented as offering superior strength and stiffness compared to screw fixation with a common goal of healing the fracture in a timely manner without associated risks [2,[6][7][8][9]. Even with superior results for medial malleolus fixation, Fowler et al. relate that the thin overlying skin, the anatomical location, and the soft tissue irritation appear to be reasons to avoid this approach [10]. "
    [Show abstract] [Hide abstract] ABSTRACT: The traditional stainless steel wire tension band (WTB) has been popularized for small avulsion fractures at the medial malleolus. Despite the tension band principle creating a stable construct, complications continue to arise utilizing the traditional stainless steel WTB with patients experiencing hardware irritation at the tension band site and subsequent hardware removal. Coupled with hardware irritation is fatigue failure with the wire. The goal of this investigation was to retrospective compare this traditional wire technique to an innovative knotless tension band (KTB) technique in order to decrease costly complications. A total of 107 patients (WTB n=89, KTB n=18) were reviewed with a minimum follow up of 1-year and a mean age of 46.2±16.4 years for the WTB and 43.2±11.1 years for the KTB at the time of surgery (p=0.442). Outcome measures include descriptive data, fracture classification, results through economic costs (including initial product costs, return to operating room costs for irritation/revision/removal of hardware), and fixation results (including hardware status, healing status, pain status, and time to healing). The KTB group had a 13% lower true cost as compared to the WTB group while the fixation results was equivocal for the measured outcomes. Our results demonstrate that the innovative KTB is comparable to the traditional WTB while offering a lower true cost, an irritation free reduction all without the frustration of returning to the operating room for additional hardware removal, which averages approximately $8,288.
    Full-text · Conference Paper · Jun 2015 · International Journal of Endocrinology
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