SLR - October 2022 - Hafsah K. Dean, DPM
Reference: Wordie SJ, Carter TH, MacDonald D, Duckworth AD, White TO. Percutaneous Fixation of Posterior Malleolar Fractures in Patients With Unstable Ankle Fractures Treated With a Fibular Intramedullary Nail: A Description of a Technique and Review of Outcomes. J Orthop Trauma. 2022 Apr 1;36(4):195-200.Level of Evidence: IV
Scientific Literature Review
Reviewed By: Hafsah K. Dean, DPM
Residency Program: Scripps Mercy Hospital, San Diego, CA
Podiatric Relevance: Unstable ankle fractures are often managed surgically in multiple different fixation methods, dependent on surgeon preference. In a patient population with one or more comorbities, there is an increased risk for poorer functional and radiographic outcomes. Recently there has been advancements in percutaneous ankle fixation to reduce soft tissue complications in this patient population. One of these advancements is an intramedullary nail for fibular fractures. In addition to fibular fracture, ankle fractures can often also include posterior malleolar fractures. This study provides a technique and outcome measurement for percutaneous fixation of posterior malleolar fractures in patients treated with fibular intramedullary nails.
Methods: A retrospective study of adult patients with unstable ankle fractures from 2008-2016 who underwent fibular nail fixation with percutaneous fixation for posterior malleolus fractures. A total of 32 adult patients were included in the study with posterior malleolar fractures with posterior talar displacement . Posterior malleolar fractures were operatively closed reduced or reduced via stab incision with periosteal elevator and two percutaneous AP screws. Primary short term outcomes include complications related to percutaneous posterior malleolar fixation. Primary midterm outcomes were evaluated using Olerud- Molander Ankle Score (OMAS). Secondary outcomes included Manchester-Oxford Foot Questionnare, EuroQol-5D, health, pain and satisfaction.
Results: 32 patients included in this study had a mean age of 65, primarily women (81.3%), and had at least one or more comorbities. Short term, 94% of posterior malleolar fractures united without complications. Two patients had postoperative loss of talar reduction. No soft tissue complications were noted. Midterm outcomes OMAS had a median score of 80. Secondary outcomes it was noted patients who were smokers had statistically poorer outcome overall.
Conclusions: The authors concluded that percutaneous posterior malleolar with fibular intramedullary nail in the setting of unstable ankle fracture in patient with comorbities is a reliable method. It provided reliable fracture stabilization and overall patient satisfaction. The limitation to the study was contentious criteria to fix a posterior malleolar fracture, which was surgeon dependent. The technique guide was also unclear about placement of anterior stab incision for AP screw to avoid any damage to dorsalis pedis and superficial peroneal nerve, but they did recognize that as a potential risk for percutaneous fixation. Overall for the high risk patient population with unstable ankle fractures this method appears to be successful and reliable to help limit complications.