Medial Malleolar Fractures: Leave them alone Gil R. Ortega, MD, MPH - PowerPoint PPT Presentation

Medial Malleolar Fractures: Leave them alone Gil R. Ortega, MD, MPH Sonoran Orthopaedic Trauma Surgeons Orthopaedic Trauma Director, Mayo Clinic Arizona Residency Program Vice Chair, Department of Surgery, Scottsdale Osborn Level 1 Trauma Center, Scottsdale, AZ, USA

Disclosures • Founding Member, Orthopaedic Board of Advisors: Carbofix • Founding Member, Orthopaedic Board of Advisors: Artross Nanobone • Consultant: Smith and Nephew

Medial Malleolar Fractures: Leave them alone • Biomechanical and clinical literature on necessity of medial malleolar fracture fixation is sparse and inconclusive • Anatomic studies show conflicting results showing both medial and lateral structures to be primary stabilizers

Medial Malleolar Fractures: Leave them alone • Few clinical studies have shown that isolated medial-sided fixation may lead to worse clinical results in bimalleolar ankle fractures and that isolated lateral-sided fixation may be as effective as dual-sided fixation and actually may provide superior clinical benefit

Show You the Evidence…Isolated Medial Malleolar Fractures • 57 patients with 57 isolated fractures of medial malleolus were treated in cast • 55 healed without further treatment • Mean combined dorsi- and plantar flexion was 52.3 degrees • Herscovici et al. Conservative treatment of isolated fractures of the medial malleolus J Bone Joint Surg Br. 2007 Jan;89(1):89-93

Show You the Evidence…Isolated Medial Malleolar Fractures • Mean short form-36 and American Orthopaedic Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 100) • No evidence of medial instability, dermatological complications, malalignment of the mortise or of post-traumatic arthritis • Herscovici et al. Conservative treatment of isolated fractures of the medial malleolus J Bone Joint Surg Br. 2007 Jan;89(1):89-93

Show You the Evidence…Bimalleolar and Trimalleolar Ankle Fractures with Medial Malleolar Fractures • 100 patients with bimalleolar or trimalleolar ankle fractures and displacement of medial malleolus less than 2 mm after ORIF of lateral component • No significant differences between 2 groups with respect to OMA (P = 0.91), AOFAS (P = 0.85), VAS (P = 0.85), or development of osteoarthritis (P = 0.22) • Reoperation and complication rates were also comparable • 4 patients treated nonoperatively developed nonunion of medial malleolus • These patients reported no functional disabilities and presented OMA, AOFAS, and VAS scores better than average • Hoelsbrekken SE et al Nonoperative treatment of the medial malleolus in bimalleolar and trimalleolar ankle fractures: a randomized controlled trial. J Orthop Trauma. 2013 Nov;27(11):633-7

Show You the Evidence…Bimalleolar and Trimalleolar Ankle Fractures with Medial Malleolar Fractures • Even in setting of anterior collicular fracture and associated deltoid injury, fixation of fibula gets rid of need for medial malleolar fixation by providing sufficient stability while fragment and deltoid ligament heal

We just don’t have the evidence yet that fixing them is better • Need prospective comparative studies evaluating fixation vs nonop of medial malleolar fractures • Need to evaluate effect of fracture geometry, displacement after fibular reduction and long- term patient-centered outcomes

Again Why Nonop for Medial Malleolar Fractures? • No consensus in literature, I recommend nonoperative management of medial malleolar fractures for patients especially with compromised soft tissue coverage on medial side • High surgical and medical risks – Uncontrolled diabetes – ESRD • Can go to ORIF if unacceptable reduction of medial malleolus and/or skin compromise

Thank You