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Study recommends fixation of larger, but not smaller, medial malleolus fragments

Issue: April 2012

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A study examining a fixation protocol for patients with bimaleolar and trimalleolar fractures in which the medial malleolus is treated with open reduction and internal fixation based on fracture size and stability indicates that fixation may not be needed in all cases.

“The results of the current study suggest that [open reduction and internal fixation] ORIF of the medial malleolar fragment in unstable ankle fractures is not always necessary,” Jason L. Pittman, MD, PhD, said during his presentation at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. “In particular, fixation of anterior collicular fractures may not be necessary. In contrast, we do recommend fixation of the supracollicular fractures as long as the skin is amenable to the procedure.”

Pittman and colleagues retrospectively reviewed data of 192 patients who were treated during a 5-year period with ORIF of the lateral malleolus. During the fixation of the lateral malleolus, the surgeon also fixed supracollicular medial malleolar fractures unless there were soft tissue concerns or if the lateral side was fixed first and the medial side was well-reduced. Intercollicular fractures were fixed if they were large enough to contain some of the deep deltoid ligament or were widely displaced after the lateral fixation, and anterior collicular fractures were fixed only in young, active patients.

The investigators excluded patients younger than 16 years and patients with ipsilateral lower extremity injuries. The patients had an average age of 44.6 years and average clinical follow-up of 38 months with telephone interviews conducted for patients unable to return for clinical evaluation. Patients graded any medial side pain after operative or nonoperative treatment of the medial malleolus using a 0 to 10 scale, and the investigators considered a rating of greater than two as indicative of pain.

The study included 42 anterior collicular, 46 intercollicular and 104 supracollicular fractures of which 21%, 67% and 83% underwent ORIF, respectively.

Incidences of pain

“Patients with anterior collicular fractures had lower incidences of medial pain when treated nonoperatively,” Pittman said. “In the intercollicular group, there was no difference between the rate of medial pain in those treated operatively and those treated nonoperatively. In the supracollicular group, 33% of patients who were treated nonoperatively reported medial pain at follow-up compared to 12% of those treated operatively.”

The researchers noted that the sample size was not large enough to demonstrate a statistical significance for the trends regarding pain in the operative vs. nonoperative groups.

In the anterior collicular fracture group, surgeons removed one medial screw in the ORIF group and found one asymptomatic nonunion of the medial malleolus that did not require treatment in the nonoperative group. Among the intercollicular group, none of the operative patients underwent hardware removal and one nonoperatively treated patient had an ORIF and bone graft for pain due to nonunion. For the supracollicular group, two ORIF patients had additional surgery to remove painful hardware and two of the nonoperative patients went on to have bone grafting and ORIF of the medial malleolus.

Intercollicular fractures

During the paper discussion, a session moderator asked Pittman how he would handle an intercollicular fracture based on his study results.

“With the intercollicular fractures, that is the gray area,” Pittman said. “It depends on how much instability you feel you have in the ankle after you have fixed the lateral side, how large the fragment is, and how displaced it is. If you are unable to fix it due to skin condition and patient comorbidities, [then] you may well have an equal result based on what we have seen.” – by Gina Brockenbrough, MA

Reference:

• Tornetta P, Mooney V, Pittman JL, et al. Is fixation of the medial malleolus necessary? Paper #629. Presented at the 2012 American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.

For more information:

• Jason L. Pittman, MD, PhD, can be reached at the Depratment of Orthopaedic Surgery, Boston Medical Center, 1 Boston Medical Pl., Boston, MA 02118; 617-638-8000; email: jpittman@bu.edu.
• Disclosure: Pittman has no relevant financial disclosures.