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Figure eight tension band in the treatment of fractures and pseudarthroses of the medial malleolus
Injury (1990) 21, 393-397
Frintrd in Great Britain
393
Figure eight tension band in the treatment of fractures and pseudarthroses of the medial malleolus T. E. Kanakis, E. Papadakis, A. Orfanos, A. Andreadakis and E. Xylouris Second Department
Between 1 Jarway
of Orthopaedic
Surgery, Venizelion
Hospital, In&lion, Crete, Greece
1981 and 30 ]une 7987, 104 closed medial malleolar
fractures and seven psardarthroses of the medial tnalleolus were treated by
tension band wiring. The ligaments, rxzpsuleand other fractures were reconstructed Most of tk fractures had hpati after 8 weeks. We re-examined 97 of tk fresh fraciures and all seven of tk psardarthroses at an average of 3.8 years after the opemficn. of tk medial malleoku fractures 92.3 per cent were excellent. In type A fractures 90 per cent were excellent, in type B fractures 92.5 per cent w&e excellent and in type C fractures 89.36 per cent were excellent. In tk group of psardarthroses six were excellent.
Introduction Malleolar fractures are among the most common fractures. The treatment of these fractures demands skill because even the smallest malposition may result in a disturbance of joint function. Anatomical reconstruction of the malleolus as well as the ligament and capsular tears is therefore essential (Heim, 1970; Ellison, 1977; Haas, 1980; Willenegger, 1981 (personal communication); Kanakis and Hierholzer, 1983).
Patients and methods We followed Weber’s (1966) classification. Between 1 January 1981 and 30 June 1987,. 104 patients with fresh closed fracture and seven patients with a pseudarthrosis of the medial malleolus were treated. Of the fresh fractures, 54 were on the right and 66 were males. Average age was 38 Table I.
Postoperative treatment All fractures were placed in a plaster splint for 5 days. Some of the type C3 fractures were put in a complete cast for 6 weeks. After removing the splint, patients started active movement. Weight bearing of about 20 kg was encouraged on the 20th day.
Results Early results The fractures healed completely by the end of the 2nd month. The motion of the ankle joint was usually complete at the end of the 3rd month. There were no deformities of
Patients from I January 1981 to 30 June 1987
Site Right Left Sex
Women Men Classification Medial malleolus only Bimalleolar Type A
Group A Fresh fractures (N = 104)
Group B Pseudarthroses (N = 7)
54 50
4 3
38
2
66
5
15
Twe C
48
Mean age: 35 years (range 1 S-72 years) Ltd
%
14.4
::
Tvpe B
0 1990 Butterworth-Heinema 002O--1383/90/060393-05
years (range 19-71 years). There were 15 fractures of the medial malleolus only (14.4 per cent), 13 were type A (12.5 per cent), 28 were type B (26.9 per cent) and 48 type C (46.2 per cent). The pseudarthrosis group consisted of two women and five men. One belonged to type B and six to type C, all of whom had previously been treated nonoperatively (Table I). The level of the medial malleolar fractures is shown in Table II The medial malleolar fractures were treated by a figure eight tension band wire combined with K-wires. The associated ruptured ligaments and capsule and other fractures were reconstructed. The pseudarthroses (seven cases) were treated operatively at an average of 5 months after the initial injury. Of these, one was type B and six were types Cl and C2. Existing osteoporosis did not affect tightening of the wire.
1 6
12.5 26.9 46.2
Injury: the British Journal of Accident Surgery (1990) Vol. 21iN0.6
394
Table II. Classificationand level of the fracturefrom the ankle joint (III cases) Type of fracture
Distal
Level
4 3 7 14
7 4 15 21
Medial malleolus A
8 C
Proximal
No. of cases (%) 15 13 28 48
t 6 13
(14.4) (12.5) (26.9j (46.2) 7
Pseudarthroses -
1
-
5
1
Table III. Questionnaire 1.5-6 years after injury Points
Pain
Excellent
Good
Fair
Poor
5-6
4
2
0
6
5
l-2
0
6
4-5
3
o-1
6
2
1
0
7-l 1
O-l
No pain At start or weather changes Pain in some positions Pain in the afternoon At night or continuous 6 5
Walking Normal Walking 6 h Walking 2 h Walking only at home No walking Normal Plantar flexion Oorsiflexion Varus Valgus
6 2 1 0 0
Radiographic results Normal Osteoporosis Malposition Post-traumatic arthritis Pseudarthrosis
Total
22-24
15-17
Table IV. Long-term results according to the questionnaire
Type of fracture Medial malleolus only
No. of cases (N= 704) 13 (15)
Results(%)
Excellent Good Excellent Good Fair Excellent Good Fair
12 1 9 1 25 1 1 42 4 1
Excellent Good
6 1
Excellent GOOd
A
10 (13)
9
27 (28)
c
47 (48)
Pseudarthroses
7 (7)
the articular surfaces, delayed union or pseudarthroses. Osteoporosis was not seen. AU patients returned to their work and athfetic activities by the end of the 3rd month, mostly with no pain or difficulties in movement. The pseudarthrosis group were no different from the fresh fracture group, except that they required intensive physiotherapy. They had also returned to work by the end of the 3rd postoperative month.
(90) (101 (92.59) I::;:; (89.36)
Long-term results Of the 104 patients, 97 (93.3 per cent) in the fresh fracture group and all seven of the pseudarthrosis group were re-examined after 1.5-6 years (average 3.5 years); that is, 13 of the 15 fractures of the medial malleolus, 10 of the 13 type A, 27 of the 28 type B, and 47 of the type C fractures. The results were graded according to the questionnaire (TubleIII), which was sent to the patients and by further
395
Kanakis et al.: The figure eight tension band
Figure 1. Medial malleolar fracture 5 years later.
Figure4. years.
Figure 2. a, Fracture type B. b, Postoperative band in both malleolis and 4 years later.
radiograph.
Figure3. a, Fracture type Cl and postoperative Five years later.
a, Fracture-dislocation
type C2. b, The same after 6
Tension
radiograph.
b,
Figure S. a, Pseudarthrosis of the ankle joint, with dislocation of the talus. Oblique osteotomy of the fibula over the syndesmosis. b, The same 4 years later.
396
Injury: the British Journal of Accident Surgery (1990) Vol. 21iN0.6
examination. Both subjective and objective criteria were recorded. Final results have been defined as excellent, good and fair (Table IV). By excellent we mean that patients were graded with 22-24 points, good 15-17 points, fair 7-11 points and poor with I or no points. Of the medial malleolar fractures, 12 patients had an excellent result (Figure I). One was a graded good because dorsiflexion was decreased by 3”. Of the type A fractures, nine patients had excellent results, and one was graded good as dorsiflexion was decreased by 3”. Of the type B fractures, 25 patients had excellent results, one was graded good because the patient had pain with weather changes and one was fair because there was a loss of 4” of dorsiflexion and difficulty in climbing stairs (Figure Zu,b). Of the type C fractures, 42 were excellent, four were graded good because there was loss of 3” of dorsiflexion and one was graded fair (type C3) because of post-traumatic arthritis 5 years after the operation (Fipres 3u,b; &b). Of the pseudarthrosis group, six had excellent results; one was graded good because there was some medial diastasis of the ankle joint (Figrrre k,b).
Discussion Many authors agree that immediate, open anatomical reduction, rigid internal fixation and early mobilization, is the method of choice in the treatment of malleolar fractures (Burwejl and Charnley, 1965; RuEdi, 1973; Miiller et al., 1979; Tunturi et al., 1983). For the distal medial malleolar fractures they proposed fixation with K-wires and figure of eight tension bands. On the other hand, for the most proximal ones, they proposed a malleolar screw and possibly K-wires or plates and screws for other fractures. Clinical applications of the above created the following problems which altered our management of fractures of the medial malleolus: 1. Of the type A and B fractures, if the medial malleolar fragment was small, internal fixation by screw might break the malleolus. If the fragment was large enough to need fixation by two screws or by a screw and K-wire, the bone fragment might break, also if the fracture was cpmminuted. If the fracture was oblique, screw placement might displace the fracture. 2. Of the type C fractures problems were greater. For these reasons, we extended the indication for a tension band with K-wires for the treatment of all types of medial malleolar fractures. This choice was based mainly on the studies of Pauwels (1935, 1965, 1976). Other authors, like Gould et al. (1984), Wallace (1987), Gordon and Monsanto (1987) investigated the wire’s biomechanical functions and came to the same conclusions as Pauwels, that the combination of tension band wire with K-wires increases stability. Investigators like Gothmann (1962, 1963) and Withrow (1978) showed that the wire does not obstruct bone healing. Wilson et al. (1985) have also shown that the wire does not influence the blood supply and bone growth.
Conclusions 1. Fixation of medial malleolar fractures using a combination of a figure of eight tension band and K-wires, is the
best method of treatment for all types of medial malleolar fractures and pseudarthroses.
The system is small and can be used on all sizes of medial malleolar fractures. It is a rigid fixation. It is necessary to reconstruct and other fractures.
the ligamentous
ruptures,
The internal fixation of ankIe joint fractures by this method has allowed immediate, active mobilization and early physical participation in normal and sporting activities.
Acknowledgements We thank Professor Dr Emm Drettakis for his suggestions
and assistance.
References BurweU H. N. and Charnley A. D. (1965) The treatment of displaced fractures of the ankle by rigid internal fixation and early joint movement. 1. &me Jtinf Stcrg.47B, 634. Ellison A. (1977) Skiing Injuries. Clinical Symposia CIBA, New Jersey. Gorton L. and Monsanto E. (1987) Skeletal stabilization for digital replantation surgery. Use of interosseous wiring. Cfin. Orthop. 214. 72. Gothmann L. (1962) Local arterial changes associated with experimental fractures of the rabbit’s tibia treated with encircling wire (cerclage). A microangiographic study. A& Chir. Sixand. 123,17. Gothmann L. (1963) Local arterial changes caused by surgical exposure and the application of encircling wires (cerclage) on the rabbit’s tibia. Acfu Chir. Scard 103,9. Gould W., Belsole R. and Skelton W. (1984) Tension-band stabilization of transverse fractures: An experimental analysis. Plasf. Rewnsfr. Surg. 73, 111. Haas P. (1980) Injury of the ankle joint. Acfa Orfhop. Hellenicn 31, 90. Heim U. (1970) Indication et techniques des sutures ligamentaires dam les fractures malleolaires. Rev. Chir. Orthop. 59‘1. Kanakis E. Th. and Hierholzer G. (1983) Acute isolated ruptures of the ligaments of the lateral malleolus. Acfa Orthop. Hellenira 34, 19. Miiller M. E., Allgiiwer M., Schneider R. et al. (1979) Manual of lntemalFix&ion: TechniqueRecommen&dby theA0 Group. 2nd Ed. Berlin, Heidelberg, New York: Springer-Verlag. Pauwels F. (1935) Der ddcelhals~h ein tnechanisches problem. Stuttgart: Enke. Pauwels F. (1965) Gesammelte Abhandlungen zurfunkfionelkn Anatomie aks Eezqungsa~arafes. Berlin, Heidelberg, New York: Springer-Verlag. Pauwels F. (1976) Biomechanicsof the Normal and Diseased Hip. Berlin, Heidelberg, New York: Springer-Verlag. Ruedi Th. (1973) Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and internal fixation. Injuy 5, 30. Tunturi T., Kemppainen K., Patiala H. et al. (1983) Importance of anatomical reduction for subjective recovery after ankle fracture. Acfa Orfhop. Scard. 54,641.
Kanakis et al.: The figure eight tension band
397
Wallace W. J. (1987) Biomechanncs of small bone fixation. Ck orthop. 214, II. Weber B. (1966) Die Verlefzungen dw aberen spruggelenkes acfuelle in der chirargie. Stuttgart Huber. Wilson J., Rhinelander F. and Stewart C. (198.5) Microvascular and histologic effect of circumferential wire on appositional bone growth in immature dogs. J. 0&p. Res. 3,412. Withrow
S. (1978) Use and Misuse
of Full Cerclage
wires in
Fracture Repair. Symposium on Controversial Problems in Clinical Practice.
Paper accepted
14 February 1990.
Reqtresk for reprints should be addresseA to: Dr Theofanis Emm Kanakis, Consultant Orthopaedic Surgeon, Second Department of Orthopaedic Surgery, Venizelion General Hospital, I43 Leoforos Knossou, Iraklion, Crete, Greece.
Frintrd in Great Britain
393
Figure eight tension band in the treatment of fractures and pseudarthroses of the medial malleolus T. E. Kanakis, E. Papadakis, A. Orfanos, A. Andreadakis and E. Xylouris Second Department
Between 1 Jarway
of Orthopaedic
Surgery, Venizelion
Hospital, In&lion, Crete, Greece
1981 and 30 ]une 7987, 104 closed medial malleolar
fractures and seven psardarthroses of the medial tnalleolus were treated by
tension band wiring. The ligaments, rxzpsuleand other fractures were reconstructed Most of tk fractures had hpati after 8 weeks. We re-examined 97 of tk fresh fraciures and all seven of tk psardarthroses at an average of 3.8 years after the opemficn. of tk medial malleoku fractures 92.3 per cent were excellent. In type A fractures 90 per cent were excellent, in type B fractures 92.5 per cent w&e excellent and in type C fractures 89.36 per cent were excellent. In tk group of psardarthroses six were excellent.
Introduction Malleolar fractures are among the most common fractures. The treatment of these fractures demands skill because even the smallest malposition may result in a disturbance of joint function. Anatomical reconstruction of the malleolus as well as the ligament and capsular tears is therefore essential (Heim, 1970; Ellison, 1977; Haas, 1980; Willenegger, 1981 (personal communication); Kanakis and Hierholzer, 1983).
Patients and methods We followed Weber’s (1966) classification. Between 1 January 1981 and 30 June 1987,. 104 patients with fresh closed fracture and seven patients with a pseudarthrosis of the medial malleolus were treated. Of the fresh fractures, 54 were on the right and 66 were males. Average age was 38 Table I.
Postoperative treatment All fractures were placed in a plaster splint for 5 days. Some of the type C3 fractures were put in a complete cast for 6 weeks. After removing the splint, patients started active movement. Weight bearing of about 20 kg was encouraged on the 20th day.
Results Early results The fractures healed completely by the end of the 2nd month. The motion of the ankle joint was usually complete at the end of the 3rd month. There were no deformities of
Patients from I January 1981 to 30 June 1987
Site Right Left Sex
Women Men Classification Medial malleolus only Bimalleolar Type A
Group A Fresh fractures (N = 104)
Group B Pseudarthroses (N = 7)
54 50
4 3
38
2
66
5
15
Twe C
48
Mean age: 35 years (range 1 S-72 years) Ltd
%
14.4
::
Tvpe B
0 1990 Butterworth-Heinema 002O--1383/90/060393-05
years (range 19-71 years). There were 15 fractures of the medial malleolus only (14.4 per cent), 13 were type A (12.5 per cent), 28 were type B (26.9 per cent) and 48 type C (46.2 per cent). The pseudarthrosis group consisted of two women and five men. One belonged to type B and six to type C, all of whom had previously been treated nonoperatively (Table I). The level of the medial malleolar fractures is shown in Table II The medial malleolar fractures were treated by a figure eight tension band wire combined with K-wires. The associated ruptured ligaments and capsule and other fractures were reconstructed. The pseudarthroses (seven cases) were treated operatively at an average of 5 months after the initial injury. Of these, one was type B and six were types Cl and C2. Existing osteoporosis did not affect tightening of the wire.
1 6
12.5 26.9 46.2
Injury: the British Journal of Accident Surgery (1990) Vol. 21iN0.6
394
Table II. Classificationand level of the fracturefrom the ankle joint (III cases) Type of fracture
Distal
Level
4 3 7 14
7 4 15 21
Medial malleolus A
8 C
Proximal
No. of cases (%) 15 13 28 48
t 6 13
(14.4) (12.5) (26.9j (46.2) 7
Pseudarthroses -
1
-
5
1
Table III. Questionnaire 1.5-6 years after injury Points
Pain
Excellent
Good
Fair
Poor
5-6
4
2
0
6
5
l-2
0
6
4-5
3
o-1
6
2
1
0
7-l 1
O-l
No pain At start or weather changes Pain in some positions Pain in the afternoon At night or continuous 6 5
Walking Normal Walking 6 h Walking 2 h Walking only at home No walking Normal Plantar flexion Oorsiflexion Varus Valgus
6 2 1 0 0
Radiographic results Normal Osteoporosis Malposition Post-traumatic arthritis Pseudarthrosis
Total
22-24
15-17
Table IV. Long-term results according to the questionnaire
Type of fracture Medial malleolus only
No. of cases (N= 704) 13 (15)
Results(%)
Excellent Good Excellent Good Fair Excellent Good Fair
12 1 9 1 25 1 1 42 4 1
Excellent Good
6 1
Excellent GOOd
A
10 (13)
9
27 (28)
c
47 (48)
Pseudarthroses
7 (7)
the articular surfaces, delayed union or pseudarthroses. Osteoporosis was not seen. AU patients returned to their work and athfetic activities by the end of the 3rd month, mostly with no pain or difficulties in movement. The pseudarthrosis group were no different from the fresh fracture group, except that they required intensive physiotherapy. They had also returned to work by the end of the 3rd postoperative month.
(90) (101 (92.59) I::;:; (89.36)
Long-term results Of the 104 patients, 97 (93.3 per cent) in the fresh fracture group and all seven of the pseudarthrosis group were re-examined after 1.5-6 years (average 3.5 years); that is, 13 of the 15 fractures of the medial malleolus, 10 of the 13 type A, 27 of the 28 type B, and 47 of the type C fractures. The results were graded according to the questionnaire (TubleIII), which was sent to the patients and by further
395
Kanakis et al.: The figure eight tension band
Figure 1. Medial malleolar fracture 5 years later.
Figure4. years.
Figure 2. a, Fracture type B. b, Postoperative band in both malleolis and 4 years later.
radiograph.
Figure3. a, Fracture type Cl and postoperative Five years later.
a, Fracture-dislocation
type C2. b, The same after 6
Tension
radiograph.
b,
Figure S. a, Pseudarthrosis of the ankle joint, with dislocation of the talus. Oblique osteotomy of the fibula over the syndesmosis. b, The same 4 years later.
396
Injury: the British Journal of Accident Surgery (1990) Vol. 21iN0.6
examination. Both subjective and objective criteria were recorded. Final results have been defined as excellent, good and fair (Table IV). By excellent we mean that patients were graded with 22-24 points, good 15-17 points, fair 7-11 points and poor with I or no points. Of the medial malleolar fractures, 12 patients had an excellent result (Figure I). One was a graded good because dorsiflexion was decreased by 3”. Of the type A fractures, nine patients had excellent results, and one was graded good as dorsiflexion was decreased by 3”. Of the type B fractures, 25 patients had excellent results, one was graded good because the patient had pain with weather changes and one was fair because there was a loss of 4” of dorsiflexion and difficulty in climbing stairs (Figure Zu,b). Of the type C fractures, 42 were excellent, four were graded good because there was loss of 3” of dorsiflexion and one was graded fair (type C3) because of post-traumatic arthritis 5 years after the operation (Fipres 3u,b; &b). Of the pseudarthrosis group, six had excellent results; one was graded good because there was some medial diastasis of the ankle joint (Figrrre k,b).
Discussion Many authors agree that immediate, open anatomical reduction, rigid internal fixation and early mobilization, is the method of choice in the treatment of malleolar fractures (Burwejl and Charnley, 1965; RuEdi, 1973; Miiller et al., 1979; Tunturi et al., 1983). For the distal medial malleolar fractures they proposed fixation with K-wires and figure of eight tension bands. On the other hand, for the most proximal ones, they proposed a malleolar screw and possibly K-wires or plates and screws for other fractures. Clinical applications of the above created the following problems which altered our management of fractures of the medial malleolus: 1. Of the type A and B fractures, if the medial malleolar fragment was small, internal fixation by screw might break the malleolus. If the fragment was large enough to need fixation by two screws or by a screw and K-wire, the bone fragment might break, also if the fracture was cpmminuted. If the fracture was oblique, screw placement might displace the fracture. 2. Of the type C fractures problems were greater. For these reasons, we extended the indication for a tension band with K-wires for the treatment of all types of medial malleolar fractures. This choice was based mainly on the studies of Pauwels (1935, 1965, 1976). Other authors, like Gould et al. (1984), Wallace (1987), Gordon and Monsanto (1987) investigated the wire’s biomechanical functions and came to the same conclusions as Pauwels, that the combination of tension band wire with K-wires increases stability. Investigators like Gothmann (1962, 1963) and Withrow (1978) showed that the wire does not obstruct bone healing. Wilson et al. (1985) have also shown that the wire does not influence the blood supply and bone growth.
Conclusions 1. Fixation of medial malleolar fractures using a combination of a figure of eight tension band and K-wires, is the
best method of treatment for all types of medial malleolar fractures and pseudarthroses.
The system is small and can be used on all sizes of medial malleolar fractures. It is a rigid fixation. It is necessary to reconstruct and other fractures.
the ligamentous
ruptures,
The internal fixation of ankIe joint fractures by this method has allowed immediate, active mobilization and early physical participation in normal and sporting activities.
Acknowledgements We thank Professor Dr Emm Drettakis for his suggestions
and assistance.
References BurweU H. N. and Charnley A. D. (1965) The treatment of displaced fractures of the ankle by rigid internal fixation and early joint movement. 1. &me Jtinf Stcrg.47B, 634. Ellison A. (1977) Skiing Injuries. Clinical Symposia CIBA, New Jersey. Gorton L. and Monsanto E. (1987) Skeletal stabilization for digital replantation surgery. Use of interosseous wiring. Cfin. Orthop. 214. 72. Gothmann L. (1962) Local arterial changes associated with experimental fractures of the rabbit’s tibia treated with encircling wire (cerclage). A microangiographic study. A& Chir. Sixand. 123,17. Gothmann L. (1963) Local arterial changes caused by surgical exposure and the application of encircling wires (cerclage) on the rabbit’s tibia. Acfu Chir. Scard 103,9. Gould W., Belsole R. and Skelton W. (1984) Tension-band stabilization of transverse fractures: An experimental analysis. Plasf. Rewnsfr. Surg. 73, 111. Haas P. (1980) Injury of the ankle joint. Acfa Orfhop. Hellenicn 31, 90. Heim U. (1970) Indication et techniques des sutures ligamentaires dam les fractures malleolaires. Rev. Chir. Orthop. 59‘1. Kanakis E. Th. and Hierholzer G. (1983) Acute isolated ruptures of the ligaments of the lateral malleolus. Acfa Orthop. Hellenira 34, 19. Miiller M. E., Allgiiwer M., Schneider R. et al. (1979) Manual of lntemalFix&ion: TechniqueRecommen&dby theA0 Group. 2nd Ed. Berlin, Heidelberg, New York: Springer-Verlag. Pauwels F. (1935) Der ddcelhals~h ein tnechanisches problem. Stuttgart: Enke. Pauwels F. (1965) Gesammelte Abhandlungen zurfunkfionelkn Anatomie aks Eezqungsa~arafes. Berlin, Heidelberg, New York: Springer-Verlag. Pauwels F. (1976) Biomechanicsof the Normal and Diseased Hip. Berlin, Heidelberg, New York: Springer-Verlag. Ruedi Th. (1973) Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and internal fixation. Injuy 5, 30. Tunturi T., Kemppainen K., Patiala H. et al. (1983) Importance of anatomical reduction for subjective recovery after ankle fracture. Acfa Orfhop. Scard. 54,641.
Kanakis et al.: The figure eight tension band
397
Wallace W. J. (1987) Biomechanncs of small bone fixation. Ck orthop. 214, II. Weber B. (1966) Die Verlefzungen dw aberen spruggelenkes acfuelle in der chirargie. Stuttgart Huber. Wilson J., Rhinelander F. and Stewart C. (198.5) Microvascular and histologic effect of circumferential wire on appositional bone growth in immature dogs. J. 0&p. Res. 3,412. Withrow
S. (1978) Use and Misuse
of Full Cerclage
wires in
Fracture Repair. Symposium on Controversial Problems in Clinical Practice.
Paper accepted
14 February 1990.
Reqtresk for reprints should be addresseA to: Dr Theofanis Emm Kanakis, Consultant Orthopaedic Surgeon, Second Department of Orthopaedic Surgery, Venizelion General Hospital, I43 Leoforos Knossou, Iraklion, Crete, Greece.