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Bicortical Fixation of Medial Malleolar Fractures: A Review of 23 Cases at Risk for Complicated Bone Healing
The Journal of Foot & Ankle Surgery 51 (2012) 39–44
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Bicortical Fixation of Medial Malleolar Fractures: A Review of 23 Cases at Risk for Complicated Bone Healing Christy M. King, DPM 1, Mathew Cobb, DPM 2, David R. Collman, DPM, FACFAS 3, Pieter M. Lagaay, DPM 4, Jason D. Pollard, DPM 5 1
Second Year Resident, Foot and Ankle Residency Program, Kaiser San Francisco Bay Area, Oakland, CA Associate at Albuquerque Associate Podiatrists, Albuquerque, NM; Former Attending Staff, Kaiser San Francisco Bay Area Residency Program, Department of Orthopedics and Podiatry, Kaiser Walnut Creek, Walnut Creek, CA 3 Attending Staff, Department of Orthopedics and Podiatry, Kaiser Modesto Medical Center, Modesto, CA 4 Attending Staff, Foot and Ankle Residency Program, Kaiser San Francisco Bay Area, and Department of Orthopedics and Podiatry, Kaiser Walnut Creek Foundation Hospital, Walnut Creek, CA 5 Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatry, Kaiser Oakland Foundation Hospital, Oakland, CA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4 Keywords: ankle complication diabetes injury internal fixation osteoporosis screw tibia trauma
Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications. Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
Supination and pronation external rotation, as well as abduction, ankle injuries commonly produce a transverse fracture of the medial malleolus (1), and most displaced medial malleolar fractures require operative treatment to achieve anatomic reduction and stability (2). The supracollicular fracture pattern that originates at the shoulder of the tibial plafond and propagates obliquely to the medial cortex is the most commonly fixated fracture (3). A transverse fracture along the midportion of the medial malleolus is another frequently observed fracture pattern. These injuries have been classified as Herscovici type C and B, respectively (4). The type of fixation used to stabilize medial malleolar fractures is determined by the fragment size and the bone Financial Disclosure: None. Conflict of Interest: None. Address correspondence to: Jason D. Pollard, DPM, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatry, Kaiser Oakland Foundation Hospital, 901 Nevin Avenue, Richmond, CA 94801. E-mail address: [email protected] (J.D. Pollard).
quality. A variety of fixation methods have been reported in different configurations, including 1 or 2 metal or bioabsorbable lag screws, tension band wiring, smooth or threaded Kirschner wires, suture anchor, and intraosseous wire loop fixation (5–29). The purchase of 2 tibial cortices with lag screws for transverse fractures of the medial malleolus has been previously described (22) and shown to improve the pullout strength of the fixation construct compared with 4.0-mm, cancellous, partially threaded screws (22,28). Irrespective of the fixation technique or construct, the goal of operative treatment is fracture stability to achieve bony union and to facilitate early mobilization for the injured patient. The prevalence of ankle fractures has increased in the elderly population (30–33). Elderly patients are not only susceptible to ankle fractures owing to poor bone quality, but also because of increased body weight, a high body mass index, polypharmacy, a propensity for falls, and tobacco use (31,34,35). The greater rates of malunion, nonunion, and loss of reduction that have been previously reported
1067-2516/$ - see front matter Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved. doi:10.1053/j.jfas.2011.09.007
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with conservative care of malleolar fractures have led to the consensus that surgical intervention is indicated in the elderly population (30,31,36). Certain comorbidities such as osteoporosis, diabetes mellitus (DM), peripheral vascular disease, kidney disease, and impaired skin healing have been associated with poorer surgical outcomes (37–39). Although some reports have noted that surgical treatment can be successful, others have described high complication rates and frequent hardware removal (37,38,40,41). With increased complications comes the greater likelihood of rehospitalization, additional surgery, and placement of patients in long-term and shortterm rehabilitation nursing facilities (33,41), all of which lead to added cost for the treatment of these common injuries. DM can also present a challenge to surgeons treating ankle fractures, regardless of patient age. Wound infection, delayed fracture healing, difficult wound healing, the development of Charcot neuroarthropathy, and an increased risk of amputation makes the decision to treat ankle fractures in diabetic patients surgically or conservatively a difficult choice (42,43). Debate also exists between surgeons regarding whether nonoperative or operative treatment is best for any patient. Surgical treatment increases the risk of complications, especially if the ankle fracture is accompanied by an open wound or soft tissue injury (42,44). Nonoperative treatment is not innocuous and has its own set of complications, including a greater rate of malunion and an increased risk of Charcot neuroarthropathy (42,44,45). Because of the increased risk of complications associated with the treatment of ankle fractures in diabetic patients, it is important to provide a stable fixation construct. In an effort to better understand the clinical outcomes associated with bicortical fixation of unstable medial malleolar fractures in a group of patients at risk of complicated bone healing, we undertook a multicenter evaluation of a series of patients who had undergone the bicortical fixation procedure. The aim of the investigation was to determine the incidence of fracture healing and to describe the prevalence of specific comorbidities, the interval required to achieve fracture healing, and the incidence of bone healing complications. Patients and Methods The Kaiser Permanente Northern California Region institutional review board approved the protocol for the present investigation. Medical charts, electronic databases, and serial radiographs were reviewed for 27 consecutive patients evaluated and treated for ankle fractures with an unstable medial malleolar fracture component that were fixated using a bicortical lag screw technique. Surgery was performed by the senior authors (M.C., D.C., P.L., J.P.) at Kaiser Permanente Oakland, Walnut Creek, Modesto, and Stockton, California, from April 2008 to August 2010. These investigators also performed the outcome assessments at the last documented office visit. The indication for surgery was an unstable ankle fracture with a medial malleolar fracture component that required fixation. The operative technique and postoperative management were similarly applied for each patient by the attending surgeons at their respective institution (see the section “Operative Technique”). Patients who had undergone open reduction-internal fixation (ORIF) of their ankle fracture (identified by the “International Classification of Diseases” [World Health Organization, Geneva, Switzerland] codes 824.0, 824.4, 824.6, and 824.8 and matched Current Procedural Terminology [American Medical Association, Chicago, IL] codes 27766, 27814, 27822, or 27823), with bicortical lag screw fixation of the medial malleolus, with a minimum of 6 months of postoperative follow-up, or those who were monitored until radiographic consolidation of the fracture was evident, were eligible for study inclusion. To be included in the present study, the patients undergoing fracture repair had to be considered to be more vulnerable to bone healing complications than the general population. For the purposes of the present study, we defined our vulnerable patient population as having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, DM, peripheral arterial disease (PAD), renal impairment (including end-stage renal disease, chronic kidney disease [CKD], or kidney transplant recipient), peripheral neuropathy, or current tobacco use. The demographic data collected included patient age, gender, the presence of any of the aforementioned comorbidities, and the fracture pattern, categorized using the Lauge-Hansen classification of ankle malleolar fractures (46). The presence of osteoporosis or osteopenia was confirmed by the results of bone mineral density measurements obtained with the use of dual energy x-ray absorptiometry bone scans. For the purposes of the present investigation, osteoporosis was defined as a spinal or hip bone mineral density of 2.5 or more standard deviations below the mean for healthy subjects (T-score 2.5 or less), and osteopenia was defined as a spinal or hip bone mineral density of 1 to 2.5 standard deviations below the mean (47). The patients were
categorized as having DM if the diagnosis was documented in the medical record, along with an abnormally elevated glycated hemoglobin (greater than 6.1%), at the patient’s preoperative history and physical examination (48). PAD was defined as nonpalpable pedal pulses (dorsalis pedis and/or posterior tibial), an abnormal ankle brachial index, or arterial stenosis observed on a computed tomographic angiogram (49,50). Renal impairment was determined by the estimated glomerular filtration rate (eGFR), with CKD defined using the Kidney Disease Outcomes Quality Initiative Committee guidelines (51) as either kidney damage or decreased kidney function (eGFR less than 60 mL/min/1.73 m2) for 3 months or more. Stage 1 CKD was categorized by an eGFR greater than 90 mL/min/ 1.73 m2, stage 2 by an eGFR of 60 to 89 mL/min/1.73 m2, stage 3 by an eGFR of 30 to 59 mL/ min/1.73 m2, stage 4 by an eGFR of 15 to 29 mL/min/1.73 m2, and kidney failure by an eGFR of less than 15 mL/min/1.73 m2 (51). A history of kidney transplantation was also recorded and categorized as a separate form of renal disease. Peripheral neuropathy was defined by the absence of protective sensation, determined by the absence of appreciation of the 5.07 (10 g of force) Semmes Weinstein monofilament on the foot and ankle at 3 locations (great toe, third metatarsal, and fifth metatarsal) (52). Postoperative complications were categorized as wound healing, deep or superficial infection, hardware-related complications, and bone healing delay or failure. For the purpose of the present study, fracture healing was defined as unequivocal radiographic trabeculation with no clinical motion across the fracture site, and the absence of any unusual edema, erythema, or increase in skin temperature at the fracture site. Malunion was recognized as union with greater than 2 mm of displacement and nonunion, by a persistent visible radiolucency or motion across the fracture site after 9 months of follow-up (53). Standard ankle weight bearing projections were used to assess the radiographic correction and union at 6 to 8 weeks postoperatively. All the ankle fractures were categorized using the Lauge-Hansen classification system (46). Bicortical fixation of the medial malleolus, defined as fixation that crossed both near and far tibial cortices, was confirmed radiographically. Operative Technique The patients were positioned supine under general or spinal anesthesia, and a thigh tourniquet was used in 20 of 23 cases for hemostasis, unless contraindicated by peripheral vascular disease or other medical or systemic reasons. In the case of an isolated medial malleolar fracture, a bump was placed under the contralateral hip to aid in positional exposure of the target medial malleolus. If present, the concomitant fibular and/or posterior €r malleolus fractures were typically fixated using a standard AO (Arbeitsgemeinschaft fu Osteosynthesefragen, AO Foundation, Davos, Switzerland) osteosynthesis technique before reduction and fixation of the medial malleolus fracture. A 4- to 5-cm curvilinear incision was then made coaxial to the longitudinal axis of the tibia just posterior to the great saphenous vein, with variable anterior extension of the incision as dictated by the fracture pattern. Dissection was continued down to the fracture, where the periosteum was reflected as necessary, and any hematoma evacuated, to allow for anatomic reduction of the medial malleolus. In the subset of patients with PAD, reduction and internal fixation were performed percutaneously by way of small incisions without debridement of the fracture interface (Fig. 1). Under fluoroscopic guidance, the fracture was manually reduced and provisionally fixated with smooth wires. The provisional fixation was placed as close to perpendicular to the fracture line as possible, starting at the distal tip of the medial malleolus and exiting the proximal lateral tibial cortex. The smooth wires were then replaced with 3.5- or 4.0-mm, fully threaded, cortical screws placed in a lag fashion, with care taken to purchase the far (proximal and lateral) tibial cortex (Figs. 2 and 3). Washers were used at the surgeon’s discretion, depending on the overall bone integrity. If the medial malleolus fragment was too small to allow for placement of 2 lag screws, the second screw was placed in positional fashion or a single smooth Kirschner wire was used for rotational stability (Fig. 4). The ankle was stressed with an external rotary force after fracture stabilization of an associated fibular fracture to evaluate the integrity of the syndesmosis. If instability was present, it was stabilized with tibia-pro-fibula screws. Postoperative care consisted of a nonweight bearing posterior “sugar tong” splint until the soft tissues were assessed 10 to 14 days postoperatively. A short leg weight bearing cast or removable cast boot was then used for full weight bearing at 2 to 6 weeks, pending radiographic evaluation and the surgeon’s discretion.
Results Of the 27 consecutive patients who had undergone bicortical fixation of an ankle fracture with an unstable medial malleolus fracture component, 22 (81.48%; 23 ankle fractures) met the inclusion criteria. The patient demographic data are summarized in Table 1. The mean age of the patients was 69.52 (range 45 to 89) years, and 17 (77.27%) were female and 5 (22.73%) male. Of the 23 ankle fractures,19 (82.61%) were categorized as supination external rotation type 4, 2 (8.7%) were pronation external rotation type 4, and 2 (8.7%) were supination adduction type 1 (Table 2). Twenty (86.95%) of 23 operations were performed with the use of thigh tourniquet hemostasis. Regarding the comorbidities, osteoporosis was present in 8 patients (36.36%), with a mean dual energy x-ray absorptiometry
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Fig. 1. Postoperative clinical appearance of 71-year-old female with diabetes mellitus, peripheral neuropathy, and peripheral arterial disease, demonstrating limited incisional approach of displaced supination external rotation stage 4 ankle fracture: (A) medial view, (B) lateral view.
scan spine density of 0.850 g/cm2 (range 0.725 to 0.983 g/cm2) and hip density of 0.815 g/cm2 (range 0.741 to 0.883 g/cm2). All the patients with osteoporosis progressed to successful medial malleolar fracture union. Of the 22 patients, 8 (36.36%) had type 2 DM, and their mean glycated hemoglobin level during the perioperative period was 7.76% (range 5.7% to 11.9%). Of the 8 patients with type 2 DM, 7 (87.5%) achieved successful union, and 1 (12.5%) had an asymptomatic nonunion. PAD was identified in 6 cases (27.27%), 5 (83.33%) of which went on to successful union, and 1 (16.67%) developed nonunion of the medial malleolar fracture. Of the 22 patients, 2 (9.09%) had CKD, 1 (4.55%) categorized as stage 3 CKD and 1 (4.55%) as stage 2 CKD after kidney transplantation. Of the 2 patients with CKD, 1 (50%) experienced successful union of the medial malleolar fracture, and 1 (50%), with stage 3 CKD, experienced medial malleolar fracture nonunion. Of the 22 patients, 7 (31.81%) had peripheral neuropathy, with 4 (18.18%) categorized as diabetic neuropathy, 1 (4.55%) alcoholic, and 2 (9.09%) idiopathic. Of the 7 neuropathic patients, 6 (85.71%) went on to
successful union of the medial malleolar fracture, and 1 (14.29%), with diabetic neuropathy, experienced medial malleolar fracture nonunion. None of the patients developed postoperative Charcot’s neuroarthropathy during the postoperative period of observation. Overall, of the 23 medial malleolar fractures, 21 (91.3%) displayed complete, uncomplicated healing, and the mean interval to complete union was 62.6 (range 42 to 156) days. There were 4 (17.39%) observed complications, including 1 (4.35%) nonunion,1 (4.35%) malunion, and 2 cases (8.7%) of painful retained hardware that required removal. The nonunion occurred in 1 patient with multiple medical problems, including PAD, DM with peripheral neuropathy, and stage 3 CKD. No postoperative infections were noted in our patients.
Fig. 2. Postoperative anteroposterior radiographic view demonstrating 2 screws used for fixation of medial malleolus fracture.
Fig. 3. Postoperative lateral radiographic view demonstrating 2 screws used for fixation of medial malleolus fracture.
Discussion Displaced medial malleolus fractures are considered unstable ankle fractures and typically require ORIF to allow for anatomic restoration
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Table 1 Description of case series* (N ¼ 23 fractures in 22 patients) Characteristic Gender Male Female Osteoporosis Peripheral arterial disease Type 2 diabetes mellitus Chronic kidney disease Any type CKD2, kidney transplantation CKD3 Peripheral neuropathy Any type Diabetic Alcoholic Idiopathic Current tobacco use
n (%) 5 17 8 6 8
(22.73) (77.27) (36.36) (27.27) (36.36)
2 (9.09) 1 (4.55) 1 (4.55) 7 4 1 2 0
(31.81) (18.18) (4.55) (9.09) (0)
Abbreviation: CKD, chronic kidney disease. * Mean age, 69.52 (range 45 to 89) years at surgery.
Fig. 4. Postoperative mortise radiographic view demonstrating single screw and Kirschner wire used for fixation of medial malleolus fracture.
and early range of joint motion. Numerous techniques have been described for ORIF of medial malleolar fractures (5–29). These fractures are commonly fixated with either compression lag screws or tension band wiring. The method of fixation is often dictated by the fracture pattern, size of the distal fracture fragment, and bone quality. Pollard et al (28) recently demonstrated a statistically significant increase in pullout strength when comparing 3.5-mm, fully threaded, bicortical screws and 4.0-mm, partially threaded, cancellous screws for the fixation of medial malleolar ankle fractures in a cadaver model. Although ORIF remains the standard of care for unstable ankle fractures in the general population, controversy exists regarding the optimal treatment in the geriatric patient and those with risk factors that compromise bone healing. During the past several decades, an increase has occurred in the prevalence and severity of ankle fractures in the elderly population that was defined for the purposes of our study as age 55 years or older (30,36,54). Several different factors predispose this patient population to fracture, including obesity, polypharmacy, female gender, smoking, history of fracture, and the propensity for falls (31,34,55). Open reduction and internal fixation of an unstable ankle fracture in an older patient can result in an increased risk because of age-related comorbidities such as osteoporosis, DM, peripheral vascular disease, and poor wound healing potential. Numerous studies have previously reported increased complication rates in surgically treated ankle fractures in the elderly (37–39,41).
However, more recent investigations have demonstrated that ORIF of unstable ankle fractures in the geriatric patient is safe and effective, with similar results when compared with those of the general population (30,33,36,40,56,57). Makwana et al (36), in a prospective randomized study, demonstrated that anatomic reduction was significantly less reliable and loss of reduction was significantly more common in patients older than 55 years of age with closed treatment of an ankle fracture. In the same study, those patients who underwent ORIF had a significantly greater functional outcome and better range of ankle motion. Ali et al (30) evaluated operative and nonoperative treatment of patients older than 60 years of age and determined that the rate of malunion was 36.3% and that of nonunion was 13.6% for those patients treated nonoperatively compared with 8.7% and 0.9%, respectively, in the surgically treated group. They also showed that patients treated surgically had a greater rate of satisfaction (95%) compared with those treated conservatively (66.7%) (30). In the present study, the mean age at ORIF was 69.52 years (range 45 to 89), and 21 (91.3%) of the 23 medial malleolar fractures had achieved union without complications. There was 1 nonunion (4.35%) and 1 malunion (4.35%). The malunion occurred in a 57-year-old female and was ultimately revised and healed without complications. The nonunion occurred in a 64-year-old female with multiple medical problems, including PAD, stage 3 CKD, and poorly controlled DM with peripheral neuropathy. Although her fracture did not consolidate on serial radiographs, the ankle was deemed stable and in acceptable alignment, and no additional intervention was required.
Table 2 Categorization of fractures in case series* (N ¼ 23 fractures in 22 patients) Categorization Lauge-Hansen classification SAD, type 1 SER, type 4 PER, type 4 Thigh tourniquet hemostasis Uncomplicated healingy Complicated healing Any complication Nonunion Malunion Painful fixation device
n (%) 2 19 2 20 21
(8.7) (82.61) (8.7) (86.95) (91.3)
4 1 1 2
(17.39) (4.35) (4.35) (8.7)
Abbreviations: PER, pronation external rotation; SAD, supination adduction; SER, supination external rotation. * Mean age, 69.52 (range 45 to 89) years at surgery. y Mean interval to bone healing, 62.6 (range 42 to 156) days.
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From our experience and understanding of the biomedical data, the treatment of patients with DM and ankle fractures poses a challenging surgical dilemma, and it is thought that DM-associated microangiopathy and peripheral neuropathy can predispose these patients to bone healing complications. The reported complications after ORIF of diabetic ankle fractures include nonunion, Charcot’s arthropathy, infection, wound complications, loss of fixation, amputation, and death (42,45,58–62). Blotter et al (59) reported that patients with insulin-dependent DM incurred a 57% complication rate compared with a 36% complication rate for patients with noninsulin-dependent DM and concluded that patients with DM were at a 2.76-fold greater risk of complications after ORIF of ankle fractures. Furthermore, early reports of surgically treated diabetic ankle fractures demonstrated poor results, with an infection rate of 21% to 60% and an amputation rate of 11% to 20% (58). These investigations suggested that surgical intervention might be ill advised for diabetic patients and elderly patients. These studies had small samples, and the level of DM control and identification of medical comorbidities were not analyzed. Costigan and Thordarson (44) reported that the diagnosis of neuropathy or the absence of pedal pulses were statistically significantly associated with the development of complications after operative treatment of ankle fractures in patients with DM. Of the neuropathic patients in their study, 11 (91.67%) experienced a surgical complication, and 10 (83.33%) of the patients with peripheral vascular disease incurred a surgical complication. In contrast, 8 (36.36%) of the patients (34.78% of the 23 fractures) in the present investigation were diagnosed with type 2 DM at surgery. Of these 8 patients, 4 (50%) had associated peripheral neuropathy, and 6 (75%) had PAD. Of the 8 patients,1 (12.5%) was a female with concomitant neuropathy and stage 3 CKD who experienced medial malleolar nonunion. In contrast, in 7 (87.5%), the medial malleolus fracture healed without complications. Osteoporosis is associated with a decreased bone mass, deterioration of trabecular architecture, brittleness, increased bone stiffness, and decreased strength (63,64), and the trabecular bone has the greatest natural capacity to act as a shock absorber that attenuates the load during weight bearing activity. The trabecular bone has 170 times greater capability to absorb shock than does cartilage and synovial fluid; thus, patients with osteoporosis have a greater risk of fracture, including low impact fractures (64), especially in the hip, spine, and radius (45,65). Measures to reduce the morbidity of osteoporosis include fall precautions, adequate intake of calcium and vitamin D, and bisphosphonate therapy. Once a fracture occurs, it is important to provide the patient with an anatomic reduction and a stable fixation construct to enable an early return to activity, thereby preventing an additional decline in the status of the injured extremity (63). Classically, tension band wiring is recommended for fixation in elderly and osteoporotic bone because of the poor trabecular bone quality in the distal tibial metaphysis (15). No current studies have compared tension band wiring and bicortical screw fixation for medial malleolus fractures. However, previous studies have suggested that bicortical screws might have increased pullout strength compared with partially threaded cancellous screws (28). Bicortical screw fixation might have a decreased tendency toward painful or prominent hardware compared with tension band wiring and therefore might be less likely to require additional surgery for hardware removal or wound healing complications. In the present study, 2 of the fracture repairs (8.7%) required hardware removal, after bone healing, because of pain attributed to the fixation. CKD, even mild forms, can adversely affect phosphorus and calcium metabolism, which can lead to demineralization and a reduction in bone resistance that can lead to a greater risk of fracture and inadequate bone healing (66). CKD can be associated with secondary hyperparathyroidism and vitamin D deficiency, which can also lead to bone loss and defects in trabecular bone quality (67). Although the
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association between CKD and foot and ankle fractures is not fully understood, the published data have shown an increased risk of hip and spine fractures in patients with even moderate CKD (67–70). O’Shaughnessy et al (71) evaluated fracture locations in patients after kidney transplantation and found that 8.3% occurred in the foot and ankle, and the risk of fracture increased with the severity of the CKD. Nikkel et al (70) investigated the incidence of fracture in renal transplant recipients and found that of the 68,814 patient charts reviewed, 22.5% of the patients had developed a fracture within 5 years after transplantation, with significant risk factors including age older than 45 years (and the association with age was even greater for those older than 65 years), white race, receipt of a deceased donor kidney, increased human leukocyte antigen mismatch, pretransplant dialysis, and aggressive immunosuppression. Fernandez et al (72) evaluated the bone mineral density of patients who had undergone renal transplant versus those receiving hemodialysis and found that the trabecular volume was lower and calcium content greater in kidney transplant patients. In contrast, the volume of fibrosis was greater in those undergoing hemodialysis. In our study, 1 patient (4.35%) had a history of stage 2 CKD after renal transplantation, and this patient did not experience a complication related to medial malleolar bicortical fixation. The other patient who had stage 3 CKD combined with PAD and diabetic peripheral neuropathy, as previously mentioned, developed an asymptomatic medial malleolar fracture nonunion. We recognize that the present study had various limitations. The present study was retrospective; however, to our knowledge, it is the first to describe a case series of bicortical fixation of medial malleolus fractures with lag screw fixation that captures the lateral tibial cortex. Moreover, the sample size was small, with a variety of health-related comorbidities. Despite the retrospective design and our small sample size, our goal was to describe what we believed were clinically important variables and outcomes related to the fixation. Furthermore, the surgeons abstracted the data and made the outcome assessments, although we also used well-established laboratory values (hard endpoints) to ascertain the comorbidities. Additionally, we did not undertake an inferential statistical analysis; thus, we were unable to determine with any degree of certainty which risk factors were influential in healing, or failure to heal, the medial malleolar fracture. The follow-up duration was limited to 6 months or until radiographic consolidation of the fracture was observed; thus, we were unable to describe the outcomes after a longer follow-up duration, as is customary in most reports of surgical outcomes. However, we believe this preliminary investigation into the clinical outcomes associated with bicortical lag screw fixation of unstable medial malleolar fracture can be used in the development of future prospective cohort studies and randomized controlled trials focusing on ankle fracture repair. In conclusion, from our findings with the present series of patients described, we believe that fixation of medial malleolar fractures with fully threaded bicortical screws is an additional and acceptable treatment, especially in higher risk patient populations with poor bone stock, including osteoporosis, and those with DM and CKD. References 1. Lauge-Hansen N. Fractures of the ankle: II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 60:957–985, 1950. 2. Reinherz RP, Henning KE, Granoff SR. Characteristics and operative management of supination external rotation ankle fractures. J Foot Surg 30:356–362, 1991. 3. Marsh JL, Saltzman CL. Ankle fractures. In: Rockwood and Green’s Fractures in Adults, 5th ed., vol. 2, pp. 2035–2037, edited by RW Bucholz, JD Heckman, Lippincott Williams and Wilkins, Philadelphia, 2001. 4. Herscovici D, Scaduto JM, Infante A. Conservative treatment of isolated fractures of the medial malleolus. J Bone Joint Surg Br 89-B:89–93, 2007. 5. Meekison DM. Some remarks on three common fractures. J Bone Joint Surg Am 27-A:80–85, 1945. 6. Callahan JJ. Recent and old fracture of the internal malleolus. J Int Coll Surg 11:354–358, 1948.
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Fink HA, Harrison SL, Taylor C, Cummings SR, Schousboe JT, Kuskowski MA, Stone KL, Ensrud KE. SOF Group. Differences in site-specific fracture risk among older women with discordant results for osteoporosis at hip and spine: Study of Osteoporotic Fractures. J Clin Densitom 11:250–259, 2008. 48. Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycemia. pp 1–41, World Health Organization, Geneva, 2006. 49. McGrae McDermott M. The magnitude of the problem of peripheral arterial disease: epidemiology and clinical significance. Clev Clin J Med 73(Suppl 4):S2–S7, 2006. 50. Anderson CA, Singh N. Vascular assessment and reconstruction of the ischemic diabetic extremity. In: Surgical Reconstruction of the Diabetic Foot and Ankle, pp. 72–79, edited by T Zgonis, Lippincott Williams & Wilkins, Philadelphia, 2009. 51. Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, Hogg RJ, Perrone RD, Lau J, Eknoyan G. 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Functional outcome after operatively treated ankle fractures in the elderly. Foot Ankle Int 30:728–733, 2009. 57. Leach WJ, Fordyce MJF. Audit of ankle fracture fixation in the elderly. J R Coll Surg Edinb 39:124–127, 1994. 58. Kristiansen B. Results of surgical treatment of malleolar fracture in patients with diabetes mellitus. Danish Med Bull 30:272–273, 1983. 59. Blotter RH, Connolly E, Wasan A, Chapman MW. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 20:687–694, 1999. 60. Low CK, Tan SK. Infection in diabetic patients with ankle fractures. Ann Acad Med Singapore 24:353–355, 1995. 61. Connolly JF, Csenstiz TA. Limb threatening neuropathic complications from ankle fractures who have juvenile onset diabetes. Clin Orthop 348:212–219, 1998. 62. Schon LC, Easley ME, Weinfeld SB. Charcot neuropathy of the foot and ankle. Clin Orthop 349:116–131, 1998. 63. Sweet MG, Sweet JM, Jeremiah MP, Galazka SS. Diagnosis and treatment of osteoporosis. Am Fam Phys 79:194–200, 2009. 64. Bhattacharya A, Watts NB, Davis K, Kotwoski S, Shukla R, Kumar Dwivedi A, Coleman R. Dynamic bone quality: a noninvasive measure of bone’s mechanical property in osteoporosis. J Clin Densiometry 13:228–236, 2010. 65. Sontag A, Krege JH. First fractures among postmenopausal women with osteoporosis. J Bone Miner Metab 28:485–488, 2010. 66. Isaia GC, Tamone C, Ravazzoli M. Fractures and chronic renal insufficiency. G Ital Nefrol 25:57–65, 2008. 67. Sprague SM. Renal function and risk of hip and vertebral fractures in older women: is it always osteoporosis? Arch Intern Med 167:115–116, 2007. 68. Kinsella S, Chavrimootoo S, Molloy MG, Eustace JA. Moderate chronic kidney disease in women is associated with fracture occurrence independently of osteoporosis. Nephron Clin Pract 116:256–262, 2010. 69. Kaji H, Yamauchi M, Yamaguchi T, Shigematsu T, Sugimoto T. Mild renal dysfunction is a risk factor for a decrease in bone mineral density and vertebral fractures in Japanese postmenopausal women. J Clin Endocrinol Metab Epub, 2010 Jul 14. 70. Nikkel LE, Hellenbeak CS, Fox EJ, Uemura T, Ghahramani N. Risk of fractures after renal transplantation in the United States. Transplantation 87:1846–1851, 2009. 71. O’Shaughnessy E, Dahl D, Smith C, Kasiske B. Risk factors for fracture in kidney transplantation. Transplantation 743:362–366, 2002. 72. Fernandez Castillo F, DeAlarcon RM, Esteban RJ, Haouari O, Planell E, Peran F, Bravo JA. Bone mineral density in patients with renal hyperparathyroidism undergoing surgery: relationship with bone parameters. Med Clin (Barc) 135:156–159, 2010.
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Bicortical Fixation of Medial Malleolar Fractures: A Review of 23 Cases at Risk for Complicated Bone Healing Christy M. King, DPM 1, Mathew Cobb, DPM 2, David R. Collman, DPM, FACFAS 3, Pieter M. Lagaay, DPM 4, Jason D. Pollard, DPM 5 1
Second Year Resident, Foot and Ankle Residency Program, Kaiser San Francisco Bay Area, Oakland, CA Associate at Albuquerque Associate Podiatrists, Albuquerque, NM; Former Attending Staff, Kaiser San Francisco Bay Area Residency Program, Department of Orthopedics and Podiatry, Kaiser Walnut Creek, Walnut Creek, CA 3 Attending Staff, Department of Orthopedics and Podiatry, Kaiser Modesto Medical Center, Modesto, CA 4 Attending Staff, Foot and Ankle Residency Program, Kaiser San Francisco Bay Area, and Department of Orthopedics and Podiatry, Kaiser Walnut Creek Foundation Hospital, Walnut Creek, CA 5 Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatry, Kaiser Oakland Foundation Hospital, Oakland, CA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4 Keywords: ankle complication diabetes injury internal fixation osteoporosis screw tibia trauma
Several methods have been described for fixation of unstable medial malleolar fractures. Certain patient populations, including the elderly, those with osteoporosis and osteopenia, and patients with diabetes mellitus, are generally known to be susceptible to complications associated with ankle fracture healing. The goal of the present retrospective investigation was to review the outcomes of a series of patients who had undergone medial malleolar fracture repair using fully threaded bicortical interfragmental compression screw fixation. Patients were included in the present series if they had undergone bicortical fixation of an unstable ankle fracture with a medial malleolar fracture component, in addition to having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, diabetes mellitus, peripheral arterial disease, end-stage renal disease, chronic kidney disease, previous kidney transplantation, peripheral neuropathy, or current tobacco use. A total of 23 ankle fractures in 22 consecutive patients met the inclusion criteria. The mean age of the patients was 69.52 (range 45 to 89) years; 17 were female (77.27%) and 5 were male (22.73%). Of the 23 medial malleolar fractures, 21 (91.3%) achieved complete, uncomplicated healing. The mean interval to union was 62.6 (range 42 to 156) days. A total of 4 complications (17.39%) were noted, including 1 nonunion (4.35%), 1 malunion (4.35%), and 2 cases of painful retained hardware (8.7%). From our experience with this series of patients, bicortical screw fixation for medial malleolus fractures appears to be an acceptable alternative for fixation that provides a stable construct for patients at greater risk of bone healing complications. Ó 2012 by the American College of Foot and Ankle Surgeons. All rights reserved.
Supination and pronation external rotation, as well as abduction, ankle injuries commonly produce a transverse fracture of the medial malleolus (1), and most displaced medial malleolar fractures require operative treatment to achieve anatomic reduction and stability (2). The supracollicular fracture pattern that originates at the shoulder of the tibial plafond and propagates obliquely to the medial cortex is the most commonly fixated fracture (3). A transverse fracture along the midportion of the medial malleolus is another frequently observed fracture pattern. These injuries have been classified as Herscovici type C and B, respectively (4). The type of fixation used to stabilize medial malleolar fractures is determined by the fragment size and the bone Financial Disclosure: None. Conflict of Interest: None. Address correspondence to: Jason D. Pollard, DPM, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics and Podiatry, Kaiser Oakland Foundation Hospital, 901 Nevin Avenue, Richmond, CA 94801. E-mail address: [email protected] (J.D. Pollard).
quality. A variety of fixation methods have been reported in different configurations, including 1 or 2 metal or bioabsorbable lag screws, tension band wiring, smooth or threaded Kirschner wires, suture anchor, and intraosseous wire loop fixation (5–29). The purchase of 2 tibial cortices with lag screws for transverse fractures of the medial malleolus has been previously described (22) and shown to improve the pullout strength of the fixation construct compared with 4.0-mm, cancellous, partially threaded screws (22,28). Irrespective of the fixation technique or construct, the goal of operative treatment is fracture stability to achieve bony union and to facilitate early mobilization for the injured patient. The prevalence of ankle fractures has increased in the elderly population (30–33). Elderly patients are not only susceptible to ankle fractures owing to poor bone quality, but also because of increased body weight, a high body mass index, polypharmacy, a propensity for falls, and tobacco use (31,34,35). The greater rates of malunion, nonunion, and loss of reduction that have been previously reported
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with conservative care of malleolar fractures have led to the consensus that surgical intervention is indicated in the elderly population (30,31,36). Certain comorbidities such as osteoporosis, diabetes mellitus (DM), peripheral vascular disease, kidney disease, and impaired skin healing have been associated with poorer surgical outcomes (37–39). Although some reports have noted that surgical treatment can be successful, others have described high complication rates and frequent hardware removal (37,38,40,41). With increased complications comes the greater likelihood of rehospitalization, additional surgery, and placement of patients in long-term and shortterm rehabilitation nursing facilities (33,41), all of which lead to added cost for the treatment of these common injuries. DM can also present a challenge to surgeons treating ankle fractures, regardless of patient age. Wound infection, delayed fracture healing, difficult wound healing, the development of Charcot neuroarthropathy, and an increased risk of amputation makes the decision to treat ankle fractures in diabetic patients surgically or conservatively a difficult choice (42,43). Debate also exists between surgeons regarding whether nonoperative or operative treatment is best for any patient. Surgical treatment increases the risk of complications, especially if the ankle fracture is accompanied by an open wound or soft tissue injury (42,44). Nonoperative treatment is not innocuous and has its own set of complications, including a greater rate of malunion and an increased risk of Charcot neuroarthropathy (42,44,45). Because of the increased risk of complications associated with the treatment of ankle fractures in diabetic patients, it is important to provide a stable fixation construct. In an effort to better understand the clinical outcomes associated with bicortical fixation of unstable medial malleolar fractures in a group of patients at risk of complicated bone healing, we undertook a multicenter evaluation of a series of patients who had undergone the bicortical fixation procedure. The aim of the investigation was to determine the incidence of fracture healing and to describe the prevalence of specific comorbidities, the interval required to achieve fracture healing, and the incidence of bone healing complications. Patients and Methods The Kaiser Permanente Northern California Region institutional review board approved the protocol for the present investigation. Medical charts, electronic databases, and serial radiographs were reviewed for 27 consecutive patients evaluated and treated for ankle fractures with an unstable medial malleolar fracture component that were fixated using a bicortical lag screw technique. Surgery was performed by the senior authors (M.C., D.C., P.L., J.P.) at Kaiser Permanente Oakland, Walnut Creek, Modesto, and Stockton, California, from April 2008 to August 2010. These investigators also performed the outcome assessments at the last documented office visit. The indication for surgery was an unstable ankle fracture with a medial malleolar fracture component that required fixation. The operative technique and postoperative management were similarly applied for each patient by the attending surgeons at their respective institution (see the section “Operative Technique”). Patients who had undergone open reduction-internal fixation (ORIF) of their ankle fracture (identified by the “International Classification of Diseases” [World Health Organization, Geneva, Switzerland] codes 824.0, 824.4, 824.6, and 824.8 and matched Current Procedural Terminology [American Medical Association, Chicago, IL] codes 27766, 27814, 27822, or 27823), with bicortical lag screw fixation of the medial malleolus, with a minimum of 6 months of postoperative follow-up, or those who were monitored until radiographic consolidation of the fracture was evident, were eligible for study inclusion. To be included in the present study, the patients undergoing fracture repair had to be considered to be more vulnerable to bone healing complications than the general population. For the purposes of the present study, we defined our vulnerable patient population as having at least 1 of the following comorbidities: age 55 years or older, osteoporosis or osteopenia, DM, peripheral arterial disease (PAD), renal impairment (including end-stage renal disease, chronic kidney disease [CKD], or kidney transplant recipient), peripheral neuropathy, or current tobacco use. The demographic data collected included patient age, gender, the presence of any of the aforementioned comorbidities, and the fracture pattern, categorized using the Lauge-Hansen classification of ankle malleolar fractures (46). The presence of osteoporosis or osteopenia was confirmed by the results of bone mineral density measurements obtained with the use of dual energy x-ray absorptiometry bone scans. For the purposes of the present investigation, osteoporosis was defined as a spinal or hip bone mineral density of 2.5 or more standard deviations below the mean for healthy subjects (T-score 2.5 or less), and osteopenia was defined as a spinal or hip bone mineral density of 1 to 2.5 standard deviations below the mean (47). The patients were
categorized as having DM if the diagnosis was documented in the medical record, along with an abnormally elevated glycated hemoglobin (greater than 6.1%), at the patient’s preoperative history and physical examination (48). PAD was defined as nonpalpable pedal pulses (dorsalis pedis and/or posterior tibial), an abnormal ankle brachial index, or arterial stenosis observed on a computed tomographic angiogram (49,50). Renal impairment was determined by the estimated glomerular filtration rate (eGFR), with CKD defined using the Kidney Disease Outcomes Quality Initiative Committee guidelines (51) as either kidney damage or decreased kidney function (eGFR less than 60 mL/min/1.73 m2) for 3 months or more. Stage 1 CKD was categorized by an eGFR greater than 90 mL/min/ 1.73 m2, stage 2 by an eGFR of 60 to 89 mL/min/1.73 m2, stage 3 by an eGFR of 30 to 59 mL/ min/1.73 m2, stage 4 by an eGFR of 15 to 29 mL/min/1.73 m2, and kidney failure by an eGFR of less than 15 mL/min/1.73 m2 (51). A history of kidney transplantation was also recorded and categorized as a separate form of renal disease. Peripheral neuropathy was defined by the absence of protective sensation, determined by the absence of appreciation of the 5.07 (10 g of force) Semmes Weinstein monofilament on the foot and ankle at 3 locations (great toe, third metatarsal, and fifth metatarsal) (52). Postoperative complications were categorized as wound healing, deep or superficial infection, hardware-related complications, and bone healing delay or failure. For the purpose of the present study, fracture healing was defined as unequivocal radiographic trabeculation with no clinical motion across the fracture site, and the absence of any unusual edema, erythema, or increase in skin temperature at the fracture site. Malunion was recognized as union with greater than 2 mm of displacement and nonunion, by a persistent visible radiolucency or motion across the fracture site after 9 months of follow-up (53). Standard ankle weight bearing projections were used to assess the radiographic correction and union at 6 to 8 weeks postoperatively. All the ankle fractures were categorized using the Lauge-Hansen classification system (46). Bicortical fixation of the medial malleolus, defined as fixation that crossed both near and far tibial cortices, was confirmed radiographically. Operative Technique The patients were positioned supine under general or spinal anesthesia, and a thigh tourniquet was used in 20 of 23 cases for hemostasis, unless contraindicated by peripheral vascular disease or other medical or systemic reasons. In the case of an isolated medial malleolar fracture, a bump was placed under the contralateral hip to aid in positional exposure of the target medial malleolus. If present, the concomitant fibular and/or posterior €r malleolus fractures were typically fixated using a standard AO (Arbeitsgemeinschaft fu Osteosynthesefragen, AO Foundation, Davos, Switzerland) osteosynthesis technique before reduction and fixation of the medial malleolus fracture. A 4- to 5-cm curvilinear incision was then made coaxial to the longitudinal axis of the tibia just posterior to the great saphenous vein, with variable anterior extension of the incision as dictated by the fracture pattern. Dissection was continued down to the fracture, where the periosteum was reflected as necessary, and any hematoma evacuated, to allow for anatomic reduction of the medial malleolus. In the subset of patients with PAD, reduction and internal fixation were performed percutaneously by way of small incisions without debridement of the fracture interface (Fig. 1). Under fluoroscopic guidance, the fracture was manually reduced and provisionally fixated with smooth wires. The provisional fixation was placed as close to perpendicular to the fracture line as possible, starting at the distal tip of the medial malleolus and exiting the proximal lateral tibial cortex. The smooth wires were then replaced with 3.5- or 4.0-mm, fully threaded, cortical screws placed in a lag fashion, with care taken to purchase the far (proximal and lateral) tibial cortex (Figs. 2 and 3). Washers were used at the surgeon’s discretion, depending on the overall bone integrity. If the medial malleolus fragment was too small to allow for placement of 2 lag screws, the second screw was placed in positional fashion or a single smooth Kirschner wire was used for rotational stability (Fig. 4). The ankle was stressed with an external rotary force after fracture stabilization of an associated fibular fracture to evaluate the integrity of the syndesmosis. If instability was present, it was stabilized with tibia-pro-fibula screws. Postoperative care consisted of a nonweight bearing posterior “sugar tong” splint until the soft tissues were assessed 10 to 14 days postoperatively. A short leg weight bearing cast or removable cast boot was then used for full weight bearing at 2 to 6 weeks, pending radiographic evaluation and the surgeon’s discretion.
Results Of the 27 consecutive patients who had undergone bicortical fixation of an ankle fracture with an unstable medial malleolus fracture component, 22 (81.48%; 23 ankle fractures) met the inclusion criteria. The patient demographic data are summarized in Table 1. The mean age of the patients was 69.52 (range 45 to 89) years, and 17 (77.27%) were female and 5 (22.73%) male. Of the 23 ankle fractures,19 (82.61%) were categorized as supination external rotation type 4, 2 (8.7%) were pronation external rotation type 4, and 2 (8.7%) were supination adduction type 1 (Table 2). Twenty (86.95%) of 23 operations were performed with the use of thigh tourniquet hemostasis. Regarding the comorbidities, osteoporosis was present in 8 patients (36.36%), with a mean dual energy x-ray absorptiometry
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Fig. 1. Postoperative clinical appearance of 71-year-old female with diabetes mellitus, peripheral neuropathy, and peripheral arterial disease, demonstrating limited incisional approach of displaced supination external rotation stage 4 ankle fracture: (A) medial view, (B) lateral view.
scan spine density of 0.850 g/cm2 (range 0.725 to 0.983 g/cm2) and hip density of 0.815 g/cm2 (range 0.741 to 0.883 g/cm2). All the patients with osteoporosis progressed to successful medial malleolar fracture union. Of the 22 patients, 8 (36.36%) had type 2 DM, and their mean glycated hemoglobin level during the perioperative period was 7.76% (range 5.7% to 11.9%). Of the 8 patients with type 2 DM, 7 (87.5%) achieved successful union, and 1 (12.5%) had an asymptomatic nonunion. PAD was identified in 6 cases (27.27%), 5 (83.33%) of which went on to successful union, and 1 (16.67%) developed nonunion of the medial malleolar fracture. Of the 22 patients, 2 (9.09%) had CKD, 1 (4.55%) categorized as stage 3 CKD and 1 (4.55%) as stage 2 CKD after kidney transplantation. Of the 2 patients with CKD, 1 (50%) experienced successful union of the medial malleolar fracture, and 1 (50%), with stage 3 CKD, experienced medial malleolar fracture nonunion. Of the 22 patients, 7 (31.81%) had peripheral neuropathy, with 4 (18.18%) categorized as diabetic neuropathy, 1 (4.55%) alcoholic, and 2 (9.09%) idiopathic. Of the 7 neuropathic patients, 6 (85.71%) went on to
successful union of the medial malleolar fracture, and 1 (14.29%), with diabetic neuropathy, experienced medial malleolar fracture nonunion. None of the patients developed postoperative Charcot’s neuroarthropathy during the postoperative period of observation. Overall, of the 23 medial malleolar fractures, 21 (91.3%) displayed complete, uncomplicated healing, and the mean interval to complete union was 62.6 (range 42 to 156) days. There were 4 (17.39%) observed complications, including 1 (4.35%) nonunion,1 (4.35%) malunion, and 2 cases (8.7%) of painful retained hardware that required removal. The nonunion occurred in 1 patient with multiple medical problems, including PAD, DM with peripheral neuropathy, and stage 3 CKD. No postoperative infections were noted in our patients.
Fig. 2. Postoperative anteroposterior radiographic view demonstrating 2 screws used for fixation of medial malleolus fracture.
Fig. 3. Postoperative lateral radiographic view demonstrating 2 screws used for fixation of medial malleolus fracture.
Discussion Displaced medial malleolus fractures are considered unstable ankle fractures and typically require ORIF to allow for anatomic restoration
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Table 1 Description of case series* (N ¼ 23 fractures in 22 patients) Characteristic Gender Male Female Osteoporosis Peripheral arterial disease Type 2 diabetes mellitus Chronic kidney disease Any type CKD2, kidney transplantation CKD3 Peripheral neuropathy Any type Diabetic Alcoholic Idiopathic Current tobacco use
n (%) 5 17 8 6 8
(22.73) (77.27) (36.36) (27.27) (36.36)
2 (9.09) 1 (4.55) 1 (4.55) 7 4 1 2 0
(31.81) (18.18) (4.55) (9.09) (0)
Abbreviation: CKD, chronic kidney disease. * Mean age, 69.52 (range 45 to 89) years at surgery.
Fig. 4. Postoperative mortise radiographic view demonstrating single screw and Kirschner wire used for fixation of medial malleolus fracture.
and early range of joint motion. Numerous techniques have been described for ORIF of medial malleolar fractures (5–29). These fractures are commonly fixated with either compression lag screws or tension band wiring. The method of fixation is often dictated by the fracture pattern, size of the distal fracture fragment, and bone quality. Pollard et al (28) recently demonstrated a statistically significant increase in pullout strength when comparing 3.5-mm, fully threaded, bicortical screws and 4.0-mm, partially threaded, cancellous screws for the fixation of medial malleolar ankle fractures in a cadaver model. Although ORIF remains the standard of care for unstable ankle fractures in the general population, controversy exists regarding the optimal treatment in the geriatric patient and those with risk factors that compromise bone healing. During the past several decades, an increase has occurred in the prevalence and severity of ankle fractures in the elderly population that was defined for the purposes of our study as age 55 years or older (30,36,54). Several different factors predispose this patient population to fracture, including obesity, polypharmacy, female gender, smoking, history of fracture, and the propensity for falls (31,34,55). Open reduction and internal fixation of an unstable ankle fracture in an older patient can result in an increased risk because of age-related comorbidities such as osteoporosis, DM, peripheral vascular disease, and poor wound healing potential. Numerous studies have previously reported increased complication rates in surgically treated ankle fractures in the elderly (37–39,41).
However, more recent investigations have demonstrated that ORIF of unstable ankle fractures in the geriatric patient is safe and effective, with similar results when compared with those of the general population (30,33,36,40,56,57). Makwana et al (36), in a prospective randomized study, demonstrated that anatomic reduction was significantly less reliable and loss of reduction was significantly more common in patients older than 55 years of age with closed treatment of an ankle fracture. In the same study, those patients who underwent ORIF had a significantly greater functional outcome and better range of ankle motion. Ali et al (30) evaluated operative and nonoperative treatment of patients older than 60 years of age and determined that the rate of malunion was 36.3% and that of nonunion was 13.6% for those patients treated nonoperatively compared with 8.7% and 0.9%, respectively, in the surgically treated group. They also showed that patients treated surgically had a greater rate of satisfaction (95%) compared with those treated conservatively (66.7%) (30). In the present study, the mean age at ORIF was 69.52 years (range 45 to 89), and 21 (91.3%) of the 23 medial malleolar fractures had achieved union without complications. There was 1 nonunion (4.35%) and 1 malunion (4.35%). The malunion occurred in a 57-year-old female and was ultimately revised and healed without complications. The nonunion occurred in a 64-year-old female with multiple medical problems, including PAD, stage 3 CKD, and poorly controlled DM with peripheral neuropathy. Although her fracture did not consolidate on serial radiographs, the ankle was deemed stable and in acceptable alignment, and no additional intervention was required.
Table 2 Categorization of fractures in case series* (N ¼ 23 fractures in 22 patients) Categorization Lauge-Hansen classification SAD, type 1 SER, type 4 PER, type 4 Thigh tourniquet hemostasis Uncomplicated healingy Complicated healing Any complication Nonunion Malunion Painful fixation device
n (%) 2 19 2 20 21
(8.7) (82.61) (8.7) (86.95) (91.3)
4 1 1 2
(17.39) (4.35) (4.35) (8.7)
Abbreviations: PER, pronation external rotation; SAD, supination adduction; SER, supination external rotation. * Mean age, 69.52 (range 45 to 89) years at surgery. y Mean interval to bone healing, 62.6 (range 42 to 156) days.
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From our experience and understanding of the biomedical data, the treatment of patients with DM and ankle fractures poses a challenging surgical dilemma, and it is thought that DM-associated microangiopathy and peripheral neuropathy can predispose these patients to bone healing complications. The reported complications after ORIF of diabetic ankle fractures include nonunion, Charcot’s arthropathy, infection, wound complications, loss of fixation, amputation, and death (42,45,58–62). Blotter et al (59) reported that patients with insulin-dependent DM incurred a 57% complication rate compared with a 36% complication rate for patients with noninsulin-dependent DM and concluded that patients with DM were at a 2.76-fold greater risk of complications after ORIF of ankle fractures. Furthermore, early reports of surgically treated diabetic ankle fractures demonstrated poor results, with an infection rate of 21% to 60% and an amputation rate of 11% to 20% (58). These investigations suggested that surgical intervention might be ill advised for diabetic patients and elderly patients. These studies had small samples, and the level of DM control and identification of medical comorbidities were not analyzed. Costigan and Thordarson (44) reported that the diagnosis of neuropathy or the absence of pedal pulses were statistically significantly associated with the development of complications after operative treatment of ankle fractures in patients with DM. Of the neuropathic patients in their study, 11 (91.67%) experienced a surgical complication, and 10 (83.33%) of the patients with peripheral vascular disease incurred a surgical complication. In contrast, 8 (36.36%) of the patients (34.78% of the 23 fractures) in the present investigation were diagnosed with type 2 DM at surgery. Of these 8 patients, 4 (50%) had associated peripheral neuropathy, and 6 (75%) had PAD. Of the 8 patients,1 (12.5%) was a female with concomitant neuropathy and stage 3 CKD who experienced medial malleolar nonunion. In contrast, in 7 (87.5%), the medial malleolus fracture healed without complications. Osteoporosis is associated with a decreased bone mass, deterioration of trabecular architecture, brittleness, increased bone stiffness, and decreased strength (63,64), and the trabecular bone has the greatest natural capacity to act as a shock absorber that attenuates the load during weight bearing activity. The trabecular bone has 170 times greater capability to absorb shock than does cartilage and synovial fluid; thus, patients with osteoporosis have a greater risk of fracture, including low impact fractures (64), especially in the hip, spine, and radius (45,65). Measures to reduce the morbidity of osteoporosis include fall precautions, adequate intake of calcium and vitamin D, and bisphosphonate therapy. Once a fracture occurs, it is important to provide the patient with an anatomic reduction and a stable fixation construct to enable an early return to activity, thereby preventing an additional decline in the status of the injured extremity (63). Classically, tension band wiring is recommended for fixation in elderly and osteoporotic bone because of the poor trabecular bone quality in the distal tibial metaphysis (15). No current studies have compared tension band wiring and bicortical screw fixation for medial malleolus fractures. However, previous studies have suggested that bicortical screws might have increased pullout strength compared with partially threaded cancellous screws (28). Bicortical screw fixation might have a decreased tendency toward painful or prominent hardware compared with tension band wiring and therefore might be less likely to require additional surgery for hardware removal or wound healing complications. In the present study, 2 of the fracture repairs (8.7%) required hardware removal, after bone healing, because of pain attributed to the fixation. CKD, even mild forms, can adversely affect phosphorus and calcium metabolism, which can lead to demineralization and a reduction in bone resistance that can lead to a greater risk of fracture and inadequate bone healing (66). CKD can be associated with secondary hyperparathyroidism and vitamin D deficiency, which can also lead to bone loss and defects in trabecular bone quality (67). Although the
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association between CKD and foot and ankle fractures is not fully understood, the published data have shown an increased risk of hip and spine fractures in patients with even moderate CKD (67–70). O’Shaughnessy et al (71) evaluated fracture locations in patients after kidney transplantation and found that 8.3% occurred in the foot and ankle, and the risk of fracture increased with the severity of the CKD. Nikkel et al (70) investigated the incidence of fracture in renal transplant recipients and found that of the 68,814 patient charts reviewed, 22.5% of the patients had developed a fracture within 5 years after transplantation, with significant risk factors including age older than 45 years (and the association with age was even greater for those older than 65 years), white race, receipt of a deceased donor kidney, increased human leukocyte antigen mismatch, pretransplant dialysis, and aggressive immunosuppression. Fernandez et al (72) evaluated the bone mineral density of patients who had undergone renal transplant versus those receiving hemodialysis and found that the trabecular volume was lower and calcium content greater in kidney transplant patients. In contrast, the volume of fibrosis was greater in those undergoing hemodialysis. In our study, 1 patient (4.35%) had a history of stage 2 CKD after renal transplantation, and this patient did not experience a complication related to medial malleolar bicortical fixation. The other patient who had stage 3 CKD combined with PAD and diabetic peripheral neuropathy, as previously mentioned, developed an asymptomatic medial malleolar fracture nonunion. We recognize that the present study had various limitations. The present study was retrospective; however, to our knowledge, it is the first to describe a case series of bicortical fixation of medial malleolus fractures with lag screw fixation that captures the lateral tibial cortex. Moreover, the sample size was small, with a variety of health-related comorbidities. Despite the retrospective design and our small sample size, our goal was to describe what we believed were clinically important variables and outcomes related to the fixation. Furthermore, the surgeons abstracted the data and made the outcome assessments, although we also used well-established laboratory values (hard endpoints) to ascertain the comorbidities. Additionally, we did not undertake an inferential statistical analysis; thus, we were unable to determine with any degree of certainty which risk factors were influential in healing, or failure to heal, the medial malleolar fracture. The follow-up duration was limited to 6 months or until radiographic consolidation of the fracture was observed; thus, we were unable to describe the outcomes after a longer follow-up duration, as is customary in most reports of surgical outcomes. However, we believe this preliminary investigation into the clinical outcomes associated with bicortical lag screw fixation of unstable medial malleolar fracture can be used in the development of future prospective cohort studies and randomized controlled trials focusing on ankle fracture repair. In conclusion, from our findings with the present series of patients described, we believe that fixation of medial malleolar fractures with fully threaded bicortical screws is an additional and acceptable treatment, especially in higher risk patient populations with poor bone stock, including osteoporosis, and those with DM and CKD. References 1. Lauge-Hansen N. Fractures of the ankle: II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 60:957–985, 1950. 2. Reinherz RP, Henning KE, Granoff SR. Characteristics and operative management of supination external rotation ankle fractures. J Foot Surg 30:356–362, 1991. 3. Marsh JL, Saltzman CL. Ankle fractures. In: Rockwood and Green’s Fractures in Adults, 5th ed., vol. 2, pp. 2035–2037, edited by RW Bucholz, JD Heckman, Lippincott Williams and Wilkins, Philadelphia, 2001. 4. Herscovici D, Scaduto JM, Infante A. Conservative treatment of isolated fractures of the medial malleolus. J Bone Joint Surg Br 89-B:89–93, 2007. 5. Meekison DM. Some remarks on three common fractures. J Bone Joint Surg Am 27-A:80–85, 1945. 6. Callahan JJ. Recent and old fracture of the internal malleolus. J Int Coll Surg 11:354–358, 1948.
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