SLR - October 2023 - Negron
Title: Is fixation of the medial malleolus necessary in unstable ankle fractures?Reference: Pinski JM, Ryan SP, Pittman JL, Tornetta P. Is fixation of the medial malleolus necessary in unstable ankle fractures? Arch Orthop Trauma Surg. 2023 Jun;143(6):2999-3005. doi: 10.1007/s00402-022-04528-9. Epub 2022 Jul 5. PMID: 35788764.
Level of Evidence: Level 2
Scientific Literature Review
Reviewed By: Nelson Negron DPM
Residency Program: Montefiore Medical Center Bronx, NY
Podiatric Relevance: This article can be valuable in guiding treatment decisions and improving patient outcomes in the realm of ankle fractures and their management. It can help minimize doing unnecessary procedures and improve patient centered care. The authors hypothesized that small medial malleolar fractures that are unlikely to add to the stability of the ankle may not require fixation, therefore we would be able to avoid the morbidity of a second surgical approach on the medial ankle.
Methods: A retrospective review of prospective data collected at two Level 1 trauma centers. Inclusion criteria were age > 16 years, minimum of 6-month follow-up, all bi-malleolar and tri-malleolar fractures requiring operative fixation. Exclusion criteria were age less than 16, concomitant ipsilateral lower extremity injury that might affect the patient’s outcome, inadequate follow-up less than 6 months, incomplete documentation, and vertical medial malleolar fractures resulting in medial instability. Fractures were then evaluated on the injury X-Rays and/or CT if available and classified as supracollicular, intercollicular, or anterior collicular fractures. Only large or significantly displaced medial malleolar fractures were fixed if the soft tissues were amenable. Primary outcome measure was the presence of medial-sided ankle pain after operative or non-operative treatment of the medial malleolar fracture after a minimum follow up of 6 months. Presence of pain was defined by a pain score of 3 or higher on a 10-point VAS pain score at the site of the medial malleolar fracture.
Results:
Supracollicular fractures: ORIF group (117 patients) – 17 (14%) complained of medial sided ankle pain with average VAS score of 5.2. Non-operative group (30 patients) – 8 (28%) complained of pain with average VAS score of 5.2.
Intercollicular Fractures: ORIF group (43 patients) - 9 (21%) complained of medial-sided ankle pain with an average VAS score of 3.9. Non-operative group (18 patients) - 4 (22%) complained of pain with an average VAS score of 4.3.
Anterior collicular fractures: ORIF group (10 patients) – 4 (40%) complained of medial-sided ankle pain with an average VAS score of 6.5. Non-operative group (39 patients)-4 patients (10%) complained of medial ankle pain with an average pain score of 6.5.
Conclusions: Authors demonstrated that fixation of the anterior collicular or nondisplaced, intercollicular medial malleolar fractures is not always necessary but it is recommended to fix supracollicular and large, displaced intercollicular medial malleolar fractures. I concluded from their results that it is generally more beneficial to fixate the supracollicular and intercollicular fractures due to its contribution to ankle stability. In the article, they state that intercollicular fractures are more difficult to identify than anterior or superior collicular fractures, which can skew the results if they are placed into the wrong category. This study can provide a treatment protocol for unstable ankle fractures and can allow us to come up with a surgical plan that is centered around the patient’s present issues.