Fixation may not be superior to non-fixation in medial malleolar fractures
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Key takeaways:
- Results showed the difference in Olerud-Molander Ankle Scores was not statistically significant between fixation and non-fixation groups.
- Results showed 20% of patients in the non-fixation group had a nonunion.
Results from a randomized clinical trial showed fixation of the medial malleolus after fibular stabilization may not be superior to non-fixation.
“When operating on unstable ankle fractures, fixation of well-reduced medial malleolar fractures after fibular stabilization was not superior to non-fixation according to the study’s primary outcome,” Tom Carter, MD, FRCSEd (Tr&Orth), told Healio. “Patients with an anatomical medial-sided fracture reduction had better clinical and radiographic outcomes.”
Researchers randomly assigned 154 patients (mean age, 56.5 years; 77% women) with a closed, unstable bimalleolar or trimalleolar ankle fracture to undergo either fixation (n = 78 patients) or had no fixation (n = 76 patients) of the medial malleolus.
The primary outcome measured was the Olerud-Molander Ankle Score 1 year following randomization. Secondary analyses included the Manchester-Oxford Foot Questionnaire, the EuroQol-5D-3L, patient-reported outcomes, return time to physical activity and radiographic outcomes.
Overall, researchers found the median Olerud-Molander Ankle Score at 1 year was higher in the fixation group (80) vs. the non-fixation group (72.5). However, this result was not statistically significant. Carter said complication rates were comparable between the two groups.
In terms of radiographic findings, Carter and colleagues found 20% of patients in the non-fixation group developed a radiographic nonunion compared with 0% in the fixation group. However, eight of the 13 nonunions in the study were categorized as asymptomatic.
“We are planning to follow these patients up over the mid[term] to long-term to assess clinical outcome and also investigate if the radiographic nonunion rate affects future patient outcome,” Carter said.
Perspective
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The authors should be congratulated on completing a prospective randomized trial of non-fixation vs. internal fixation of medial malleolar fractures associated with bimalleolar or trimalleolar ankle fractures.
It should be emphasized that the study was limited to those with 2 mm or less of medial malleolar displacement.
My takeaway is that outcome was largely determined by medial malleolar healing. Patients who healed their medial malleolar fractures did similarly regardless of treatment. Patients who developed a nonunion did more poorly based on the primary outcome measure, the Olerud-Molander Ankle Score. The only patients who developed nonunion were those treated without fixation, and the rate of complications was similar between groups.
A stated conclusion of the study was that the “results support selective non-fixation of anatomically reduced medial malleolar fractures after fibular fixation.” However, there was not power to identify a specific patient population at risk for nonunion with non-fixation. Therefore, surgeons cannot predict which patients can safely be treated without fixation to avoid medial malleolar nonunion.
As 20% of patients without fixation developed a nonunion, predictors of nonunion were absent and complication rates were similar, a rational alternative conclusion from this study could be that fixation of medial malleolar fractures with displacement of 2 mm or less is prudent.
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Carter TH, et al. JAMA Netw Open. 2024;doi:10.1001/jamanetworkopen.2023.51308.
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