Older patients see return to pre-fracture function with osteosynthetic augmented internal fixation technique

Assal M. J Orthop Trauma. 2011. doi:10.1097/BOT.0b013e318214bf1b

Surgeons using an augmented internal fixation osteosynthesis technique found an increase in early weightbearing in older patients with OTA 44-B malleolar fractures, according to a recent study.

Perspective from Graeme S. Carlile, MBChB, MRCS

Matthieu Assal, MD, and his colleagues performed augmented internal fixation using intramedullary wire, lateral plate and screw augmentation with polymethylmethacrylate in 36 non-consecutive patients with OTA 44-B fractures. They measured whether the technique had an impact on postoperative function and the patients’ AOFAS scores.

The results showed that all fractures healed with no loss of reduction, according to the abstract. Patients began tolerable weighbearing in a removable brace at a mean of 13.5 postoperative days. Thirty patients were available for 12-month follow-up.

Two infections were recorded. The mean AOFAS score measuring the ankle and hindfoot was 84.9, and 90% of patients regained pre-fracture function, according to the abstract.

Perspective

Graeme S. Carlile, MBChB, MRCS

This is a controversial paper that for me, raises more questions than it answers. Fundamentally, I have reservations towards any technique that advocates the use of bone cement in achieving osteosynthesis. I simply do not agree with the authors that despite the wealth of implants available today such as locking plates and specifically designed IM fibula devices, that a surgeon really needs to resort to PMMA in order to achieve adequate purchase. I also doubt that a 2.5mm IM wire adds little to the overall construct in osteoporotic bone. I have concerns that this technique would be difficult to revise and salvage, in a patient group more likely to experience complications.

What this study lacks, is randomisation and a control group. Patients were prospectively recruited by the surgeons themselves, introducing bias. We have no matched control group for comparison, raising the possibility that patients treated with mainstream techniques may have fared just as well.

I recognise the authors are proposing this technique for limited use in a specific patient group that poses a challenging clinical problem, and not every ankle fracture. However in my opinion, there is a wealth of more sensible options available, before reaching for the cement as a last resort.

Graeme S. Carlile, MBChB, MRCS

Trauma and Orthopaedics Department

Plymouth Hospitals NHS Trust

United Kingdom

Disclosures: Carlile has no relevant financial disclosures.