The ankle study was performed at Aker University Hospital during the time period 2002-2010 and results were published in the Journal of Orthopaedic Trauma in 2013 1. The purpose of the trial was to investigate if internal fixation of an undisplaced medial malleolar fractures is necessary following open reduction and internal fixation of the lateral malleolus.

Fracture of the medial malleolus treated without (A) or with (B) internal fixation.


Patients participating in the study were followed for an average of three years, and treatment outcomes were evaluated by the use of two different scoring systems focusing on functional results. Pain was assessed by the use of an analog visual pain scale (VAS) and radiographs were examined to identify the development of posttraumatic arthritis. Based on these outcome measures we found no significant differences when comparing patients treated with and without internal fixation of the medial malleolus.

The Olerud Molander Ankle score (OMA) is a self-administered patient questionnaire based on nine items: pain, stiffness, swelling, stair climbing, running, jumping, squatting, supports and activities of daily living. The AOFAS score includes three subcategories for pain, function and alignment. Both the AOFAS and OMA scoring systems employ a scale ranging from 0 to 100 with higher scores indicating better results. Pain was measured by the use of a VAS scale with the end-points 100 representing absence of pain and 0 representing severe pain.


There were no statistical significant differences with respect to complications when comparing the two treatment groups, and the observed differences did not exceed what was expected due to normal variation. Most of the complications were easily treated and simple superficial infections constituted the majority of wound infections. Moreover, there were no serious instances of deep venous thrombosis (DVT).

Malreduction which refers to fracture malalignment, is based on the examination of postoperative radiographs and does not necessarily correlate with poorer function. Although infrequent, the most feared complications are deep infections and the development of posttraumatic arthritis. Posttraumatic arthritis signifies the destruction of the joint surfaces.

Complication-rates in percent. There were no instances of malunion in the patient group treated with internal fixation of the medial malleolus.
Complication-rates in percent. There were no instances of deep venous thrombosis in the patient group treated without internal fixation of the medial malleolus.


The advantages of non-operative treatment of the medial malleolus are shorter duration of surgery and avoidance of implant related complications such as malpositions and infections on the medial side. However, the risk of these complications is low and surgery can be carried out with relative ease. Furthermore, the risk of nonunion of the medial malleolus was higher in the group treated without fixation, and although patients developing nonunion presented results similar to patients with uncomplicated fracture healing, the data has to be interpreted with caution. Consequently, there is no reason to change the current guidelines unless medial soft tissue injuries prevent surgery.
Principal investigator
Sigurd Erik Hoelsbrekken, Specialty registrar, Kongsvinger Hospital

Knut Strømsøe, Professor Emeritus, Oslo University Hospital

Kjersti Kaul-Jensen, Specialty registrar, Lovisenberg Diakonale Hospital
Thale Mørch, Specialty registrar, Akershus University Hospital
Håvard Vika, General practitioner, Volvat Medical Centre
Torkil Clementsen, Clinic Director, Vestre Viken HF
Øyvind Paulsrud, Consultant, Oslo University Hospital
Gunnar Petursson, Consultant, Lovisenberg Diakonale Hospital
Morten Stiris, Consultant, Unilabs radiology Bryn