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.
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.
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.
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.
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