To fix or not to fix: a novel approach to the safe management of unstable open medial malleolar fractures

Carter, Thomas H.; Arthur, C.; Duckworth, Andrew D.; White, T O

doi:10.1136/bcr-2018-228965

Cited by 2 publications

(2 citation statements)

References 18 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We excluded 26 patients with open fractures (4% of the excluded group), with most having a medial laceration. Considering the potential for increased soft tissue complications with these injuries, nonfixation may in fact be more beneficial to this specific cohort . Although patient outcomes, including complications, have been documented to 1 year, the implications of a clinically silent radiographic nonunion may not be recognized for several years, and longer-term surveillance is required.…”

Section: Discussionmentioning

confidence: 99%

“…Considering the potential for increased soft tissue complications with these injuries, nonfixation may in fact be more beneficial to this specific cohort. 41 Although patient outcomes, including complications, have been documented to 1 year, the implications of a clinically silent radiographic nonunion may not be recognized for several years, and longer-term surveillance is required. For participants in the fixation group, numerous surgeons saved only final intraoperative imaging, and consequently a retrospective assessment of the medial malleolar reduction for quality control purposes cannot be performed in the same manner as for the nonfixation group.…”

Section: Limitationsmentioning

confidence: 99%

See 1 more Smart Citation

Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures

Carter,

Oliver,

Bell

et al. 2024

JAMA Netw Open

View full text Add to dashboard Cite

ImportanceUnstable ankle fractures are routinely managed operatively. However, because of soft tissue and implant-related complications, recent literature has reported on the nonoperative management of well-reduced medial malleolus fractures after fibular stabilization, but with limited evidence supporting the routine application.ObjectiveTo assess the superiority of internal fixation of well-reduced (displacement ≤2 mm) medial malleolus fractures compared with nonfixation after fibular stabilization.Design, Setting, and ParticipantsThis superiority, pragmatic, parallel, prospective randomized clinical trial was conducted from October 1, 2017, to August 31, 2021. A total of 154 adult participants (≥16 years) with a closed, unstable bimalleolar or trimalleolar ankle fracture requiring surgery at an academic major trauma center in the UK were assessed. Exclusion criteria included injuries with no medial-sided fracture, open fractures, neurovascular injury, and the inability to comply with follow-up. Data analysis was performed in July 2022 and confirmed in September 2023.InterventionsOnce the lateral (and where appropriate, posterior) malleolus had been fixed and satisfactory intraoperative reduction of the medial malleolus fracture was confirmed by the operating surgeon, participants were randomly allocated to fixation (n = 78) or nonfixation (n = 76) of the medial malleolus.Main Outcome and MeasureOlerud-Molander Ankle Score (OMAS) 1 year after randomization (range, 0-100 points, with 0 indicating worst possible outcome and 100 indicating best possible outcome).ResultsAmong 154 randomized participants (mean [SD] age, 56.5 [16.7] years; 119 [77%] female), 144 (94%) completed the trial. At 1 year, the median OMAS was 80.0 (IQR, 60.0-90.0) in the fixation group compared with 72.5 (IQR, 55.0-90.0) in the nonfixation group (P = .17). Complication rates were comparable. Significantly more patients in the nonfixation group developed a radiographic nonunion (20% vs 0%; P &lt; .001), with 8 of 13 clinically asymptomatic; 1 patient required surgical reintervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome.Conclusions and RelevanceIn this randomized clinical trial comparing internal fixation of well-reduced medial malleolus fractures with nonfixation, after fibular stabilization, fixation was not superior according to the primary outcome. However, 1 in 5 patients developed a radiographic nonunion after nonfixation, and although the reintervention rate to manage this was low, the future implications are unknown. These results support selective nonfixation of anatomically reduced medial malleolar fractures after fibular stabilization.Trial RegistrationClinicalTrials.gov Identifier: NCT03362229

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Limitationsmentioning

confidence: 99%

Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures

Carter,

Oliver,

Bell

et al. 2024

JAMA Netw Open

View full text Add to dashboard Cite

show abstract

Management of Open Ankle Fractures in Elderly Patients With a Fibula Nail is a Safe and Reliable Technique

Odeh

Archer

Budair

et al. 2022

Foot & Ankle Specialist

View full text Add to dashboard Cite

Background: Ankle fractures are becoming more common in the elderly and their management is frequently challenging. There is increasing evidence of good outcomes following fibula nail fixation in the management of ankle fractures. The use of a fibula nail in open fractures comes with potential advantages such as minimal soft tissue dissection, early rehabilitation, and decreased wound complications. We aimed to assess their use in the management of open ankle fractures in the elderly. Methods: A review of patients aged 60 years or older with an open ankle fracture treated with a fibular nail at a major trauma center was conducted. All patients were managed with joint Orthopaedic and Plastic Surgical input to determine their optimal management. Functional outcome scores, postoperative complications, and re-operation rates were determined. Results: Fifteen patients were identified with a mean age of 76 years. Patient-reported outcomes (Olerud and Molander Score) were calculated in 73% of patients. Our results demonstrated excellent outcome scores (>91) in 1 patient, good outcome scores (61-90) in 7 patients, and fair outcome scores (31-60) in 3 patients. There were no postoperative complications or re-operations within our study group. Conclusion: This article is the largest series presenting the outcomes of fibula nails in the management of open ankle fractures in elderly patients. We conclude that it can be used as a treatment option to safely manage open ankle fractures in the elderly. It provides a stable fixation, early weight-bearing, low risk of postoperative complications while maintaining good patient-reported functional outcomes. Level of Evidence: Level 4

show abstract

To fix or not to fix: a novel approach to the safe management of unstable open medial malleolar fractures

Cited by 2 publications

References 18 publications

Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures

Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures

Management of Open Ankle Fractures in Elderly Patients With a Fibula Nail is a Safe and Reliable Technique

Contact Info

Product

Resources

About