The Journal of Foot & Ankle Surgery xxx (2016) 1–5

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Original Research

Comparison of Medial Malleolar Fracture Healing at 8 Weeks After

Open Reduction Internal Fixation Versus Percutaneous Fixation:
A Retrospective Cohort Study
Glenn M. Weinraub, DPM, FACFAS 1, Patrick Levine, DPM 2, Eric Shi, DPM 2,
Aarron Flowers, DPM 2
1
Attending Physician, Department of Orthopaedic Surgery, The Permanente Medical Group, San Leandro, CA
2
Resident Physician, Kaiser Permanente South Bay Consortium, Santa Clara, CA

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 3 Unstable medial malleolar fractures are treated with either standard open reduction internal fixation (ORIF) or
a percutaneous approach. The percutaneous approach avoids the potentially excessive soft tissue dissection
Keywords:
ankle associated with an open approach but can also result in inadequate anatomic reduction. No studies have
fracture compared the incidence of radiographic healing of medial malleolar fractures between an open approach and
healing percutaneous fixation. A retrospective comparative study was performed at a single institution across multiple
pinning sites. Electronic medical records and digital radiographs were reviewed for 845 patients who had undergone
surgery either ORIF or percutaneous screw fixation (PSF) of a medial malleolar fracture. The interval to fracture healing
technique was measured. Logistic regression analysis was used. Of the 490 included patients, 458 (93.44%) underwent
standard ORIF and 32 (6.53%) underwent PSF. Patients who underwent ORIF were 5 times more likely to have a
healed fracture at 8 weeks than were patients who had undergone PSF (p < .001). Compared with standard
ORIF, PSF of medial malleolar fractures leads to an increased risk of an unhealed fracture at 8 weeks. This was
likely due to a combination of soft tissue interposition within the fracture site and inadequate fluoroscopic
reliability, leading to poor anatomic reduction and inaccurate fixation.
Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.

Ankle fractures are one of the most common types of fractures
encountered by the orthopedic foot and ankle surgeon (1). The
operative goals are to achieve a stable ankle with maximal function, to
restore the ankle mortise and reduce the risk of post-traumatic
degenerative changes (2). Supination, pronation, external rotation,
and abduction are all mechanisms that can result in a fracture of the
medial malleolus (3). These fractures can occur in isolation or in
conjunction with a fibular fracture, posterior malleolar fracture, or
tibial plafond fracture. In the early days of ankle fracture surgery, the
medial malleolus was considered the main stabilizer of the ankle
mortise, but this was later disproved in a landmark report in 1979 by
Yablon et al (4), which shifted the focus to the lateral malleolus.
Despite later studies that emphasized the importance of the medial
malleolus and deltoid ligament as the primary sources of ankle
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: Eric Shi, DPM, Department of Podiatry, Kaiser Per-
manente Suth Bay Consortium, Santa Clara Medical Office Building, 710 Lawrence
Expressway, Santa Clara, CA 95051.
E-mail address: ericfshi@gmail.com (E. Shi).
stability, limited attention has been given to treatment options and
surgical outcomes of medial malleolar fractures (5).
Open reduction and internal fixation (ORIF) can be considered the
standard approach to the treatment of unstable and displaced medial
malleolar fractures (4,6). Many fixation methods have been
described, including Kirschner wire, suture anchors, intraosseous
wire loop fixation, and antiglide plating (7–11). Studies have shown
that the most stable fixation methods include compression lag
screws or figure-of-eight tension band wiring (5,12–14). The choice
of fixation is often determined by the fracture pattern, fragment size,
and bone quality. A standard approach to ORIF of a medial malleolar
fracture involves an anteromedial approach with a longitudinal
incision centered over the medial malleolus or a J-shaped incision
(15,16). This allows for direct visualization of the fracture line, fol-
lowed by excavation of the fracture hematoma and removal of soft
tissue interposition before achieving anatomic reduction and stable
fixation (17).
Percutaneous screw fixation (PSF) has been advocated for a
variety of minimally to nondisplaced fractures of the ankle,
including posterior, lateral, and medial malleolar fractures (18,19).
The advantages of a percutaneous approach are that it avoids

1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2016.11.003
2 G.M. Weinraub et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5

Table 1 smoking, diabetes, osteoporosis, peripheral vascular disease, and

Demographic and clinical characteristics stratified by surgical procedure neuropathy, and observed the effect of these factors on the incidence
ORIF (n ¼ 458) PSF (n ¼ 32) p Value* of fracture healing. Our hypothesis was that patients who undergo PSF
Age at surgery (yr) 46.7  18.4 45.6  17.6 .74 would encounter a greater incidence of delayed union or nonunion
Gender .01 compared with patients who undergo ORIF.
Male 235 (51.3) 24 (75.0)
Female 223  (48.7) 8 (25.0)
Patients and Methods
Race .26
White 283 (61.8) 22 (68.8)
The present study was a retrospective, comparative medical review of a cohort of
Black 24 (5.2) 3 (9.4)
patients within a single healthcare system. Our institutional review board approved
Other 151 (33.0) 7 (21.9)
the present study before the study started. The inclusion criteria were an oblique,
BMI (kg/m2) 29.1  6.4 28.7 (6.5) .71
vertical shear, or transverse medial malleolar fracture treated with either ORIF or PSF
Fracture healed at 8 wk 423 (92.4) 23 (71.9) <.001
from January 2008 to December 2012. With help from the Kaiser Permanente Divi-
Postoperative protocol .31
sion of Research, these patients were identified and accrued using the appropriate
Standard 410 (89.5) 27 (84.4)
Current Procedural Terminology (American Medical Association, Chicago, IL) codes
Early weightbearing 36 (7.9) 3 (9.4)
79.87 and 79.36.
Other 12 (2.6) 2 (6.3)
Side of procedure .85
Right 248 (54.1) 18 (56.3) Intervention
Left 206 (45.0) 14 (43.8)
Unknown 4 (0.9) 0 (0) All patients were evaluated and underwent surgery by a foot and ankle surgeon
Interposed soft tissuey 361 (93.3) NA NA within the Kaiser Permanente Northern California Healthcare System. For each patient,
Smoking 188 (41.0) 10 (31.3) .27 fixation by either ORIF or PSF was determined by the fracture pattern identified on
Diabetes 59 (12.9) 5 (15.6) .59 radiographs at the discretion of the treating surgeon. In the ORIF group, the presence of
Osteoporosis 65 (14.2) 2 (6.3) .29 interposed soft tissue within the fracture site was noted and removed before anatomic
PVD 36 (7.9) 1 (3.1) .50 reduction and fixation with a combination of screws, plates, or tension banding. In the
Neuropathy 48 (10.5) 3 (9.4) 1.00 PSF group, all fractures were closed reduced, and after making a percutaneous incision,
Abbreviations: BMI, body mass index; NA, not applicable; ORIF, open reduction internal 1 to 2 guidewires were driven across the fracture site under fluoroscopic guidance. The
fixation; PSF, peripheral screw fixation; PVD, peripheral vascular disease; SD, standard fracture was then fixated with one to two 4.0-mm cannulated screws driven over the
deviation. guidewire, and a final fluoroscopic image was taken to ensure proper screw positioning
Data presented as mean  standard deviation or n (%). and fracture reduction.
* p Values for continuous variables calculated using t tests; p values for categorical Postoperatively, all patients in the PSF group remained non-weightbearing for
variables calculated using Fisher’s exact tests. 6 weeks. In the ORIF group, the patients began partial weightbearing, defined as 50%
y toe-touch weightbearing, either at 2 weeks or remained non-weightbearing for the
Because of missing data (n ¼ 95), no p value was calculated for interposed soft
tissue. entire 6 weeks. This decision was determined by the treating surgeon who performed
the case.

excessive soft tissue dissection and decreases the risk of the
wound healing complications associated with ORIF. This would
make PSF an ideal option for patients with comorbidities such as
osteoporosis, diabetes, peripheral vascular disease, and tobacco
smoking (20–22).
No studies have directly compared the results of PSF and ORIF in
the treatment of medial malleolar fractures. The purpose of the pre-
sent investigation was to compare the incidence of radiographic
healing of medial malleolar fractures at 8 weeks between ORIF and
PSF. We also measured the incidence of comorbidities, including
Outcome Measures
Electronic medical records and digital radiographs were reviewed by 2 of us (G.W.,
P.L.) to collect all variable outcomes. The primary outcome measured was the interval to
radiographic fracture union within 8 weeks after the date of surgery. This was deter-
mined by a review of the digital radiographs by 1 of us (P.L.), with the reviewer unaware
of which of the 2 surgical techniques had been used. Fracture union was determined
when no fracture line was observed and the cortical borders were intact. The presence
of interposed soft tissue in the ORIF group was noted from the operative notes. The
secondary variables measured included patient age, gender, race, body mass index, and
comorbidities, including a history of smoking, diabetes, osteoporosis, peripheral
vascular disease, and neuropathy.

Table 2
Risk analysis of fracture healed at 8 weeks postoperatively (N ¼ 490 patients)

Variable Univariate Multivariate

OR (95% CI) p Value OR (95% CI) p Value

Surgical procedures
ORIF (reference, PSF)* 4.7 (2.0 to 11.0) <.001 5.0 (1.9 to 12.4) <.001
SWB (reference, all others)* 2.3 (1.1 to 5.2) .04 2.5 (1.0 to 5.7) .03
Interposed soft tissue (reference, none) 0.4 (0.1 to 3.0) .72 NA NA
Patient characteristics
Age 60 yr (reference, <60 yr)* 0.4 (0.2 to 0.8) .006 0.5 (0.2 to 1.1) .08
Male (reference, female) 0.9 (0.5 to 1.7) .87 NA NA
Black (reference, white)* 0.3 (0.1 to 0.7) .006 0.3 (0.1 to 0.8) 0.02
Other (reference, white)* 1.2 (0.6 to 2.6) .56 1.1 (0.5 to 2.6) 0.72
BMI 30 kg/m2 (reference, <30 kg/m2) 0.5 (0.3 to 1.0) .07 NA NA
Smoking (reference, none) 0.9 (0.5 to 1.6) .75 NA NA
Diabetes mellitus (reference, none) 0.4 (0.2 to 0.7) .008 NA NA
Osteoporosis (reference, none) 0.5 (0.2 to 1.1) .10 NA NA
PVD (reference, none) 0.3 (0.1 to 0.6) .003 NA NA
Neuropathy (reference, none)y 0.3 (0.1 to 0.5) <.001 0.3 (0.1 to 0.9) .02

Abbreviations: BMI, body mass index; CI, confidence interval; NA, not applicable; OR, odds ratio; ORIF, open reduction internal fixation; PSF, percutaneous screw fixation; PVD,
peripheral vascular disease; SWB, standard weightbearing.
* Variables chosen for multivariate analysis according to univariate p value  .05 and model fit statistics.
y
Because of correlation among comorbidity variables, only neuropathy chosen for multivariate analysis.
 G.M. Weinraub et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
Fig. 1. Percutaneous pinning at 9 weeks. (A) Intraoperative fluoroscopic image. (B) Radiograph at 12 weeks postoperatively.
Statistical Analysis
All demographic characteristics of the patients were summarized for the ORIF
and PSF treatment groups. The groups were compared using a 2-tailed Student’s t test
for continuous variables and a chi-square test for categorical variables. The p values
for continuous variables were calculated using t tests, and the p values for categorical
variables were calculated using Fisher’s exact tests. Because of missing values, no p
value was calculated for interposed soft tissue. Univariate and multivariate logistic
regression analyses were performed to assess the probability of a fracture having
healed at 8 weeks in each of the treatment groups, based on a univariate p value of 
.05 and model fit statistics to achieve statistical significance. Because of the corre-
lation among the morbidity variables, only neuropathy was chosen for a multivariate
model.
Results
A total of 490 patients met inclusion criteria and were included in
the present study. Of the 490 patients, 259 (52.9%) were male and 231
(47.1%) were female, with a mean age of 46.2 (range 18 to 91) years. Of
the 490 patients, 458 (93%) had undergone ORIF and 32 (6.5%) had
undergone PSF (Table 1). The ORIF group included 235 male (51.3%)
and 223 female (48.7%) patients, with a mean age of 46.7  18.4 years.
The PSF group included 24 male (75.0%) and 8 female (25.5%) patients,
with a mean age of 45.6  17.6 years. A statistically significant
Fig. 2. Percutaneous pinning at 12 weeks. (A) Intraoperative fluoroscopic image. (B) Radiograph at 9 weeks postoperatively.
3
difference was present in the gender ratio between the ORIF and PSF
groups (p ¼ .01). The number of patients with healed fractures at
8 weeks in the ORIF group was 423 (92.4%) compared with 23 (71.9%)
in the PSF group, and this difference was statistically significant
(p < .001). Of the 458 patients who underwent ORIF, soft tissue
interposition was noted in 361 (93.3%).
When considering fracture healing at 8 weeks, multivariate lo-
gistic regression analysis adjusted according to a univariate p value of
 .05 demonstrated that the odds ratio in the ORIF group was about 5
times that of the PSF group (odds ratio 5.0, 95% confidence interval 1.9
to 12.4; p < .001; Table 2). Of the patient characteristics measured, the
significant risk factors for fracture healing by 8 weeks were age 60
years (p ¼ .006), black race (p ¼ .006), and the presence of neuropathy
(p < .001). Osteoporosis, body mass index, a history of smoking, a
history of diabetes, and a history of peripheral vascular disease were
not statistically significant risk factors for fracture healing at 8 weeks.
Discussion
To our knowledge, the present study was the first to directly
compare the results of PSF and ORIF in the treatment of transverse or
oblique medial malleolar fractures. The purpose of the present
4 G.M. Weinraub et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
investigation was to compare the incidence of radiographic healing of
medial malleolar fractures at 8 weeks between ORIF and PSF.
Although many studies have described different fixation methods for
the treatment of medial malleolar fractures (7–13,23,24), ours was the
first to compare the fracture healing outcomes between PSF and ORIF.
The results of the present study have shown that PSF leads to a
significantly increased risk of an unhealed fracture at 8 weeks
compared with ORIF. Several factors can be attributed to the cause of a
decreased incidence of fracture healing with the PSF approach. Also,
of the 458 patients who underwent ORIF, soft tissue interposition was
noted in 361 (93.3%). The mechanism of injury of the medial malleolar
fractures pulls the periosteum into the fracture site and delays frac-
ture healing. Percutaneous fixation has been well described in the
treatment of wrist fractures (25–28). Unlike medial malleolar frac-
tures, the nonrotational mechanism of injury of most wrist fractures
will not pull the periosteum into the fracture site.
In the PSF group, multiple patients had adequate reduction
confirmed by fluoroscopy, as noted in the operative report. However,
malreduction of the fracture was seen on the first postoperative ra-
diographs (Figs. 1 and 2). Fluoroscopic imaging has been shown to
produce differences in alignment compared with standard radio-
graphs (29). It can be presumed that the best method of fracture
fixation would be through an open approach that directly visualizes
the fracture site to allow for optimal anatomic reduction.
The treatment of ankle fractures in the elderly and those with
comorbidities such as osteoporosis, diabetes, peripheral vascular
disease, and tobacco smoking continues to be a challenge for ortho-
pedic foot and ankle surgeons. Diabetes, specifically diabetic neu-
ropathy, is associated with decreased bone mineral density (30) and
increased complications in bone and wound healing (20). The
growing group of elderly patients has similar risks of complications in
bone and wound healing (31–34). The data from the present study
support these trends, showing a significant risk of fracture healing at
the 8-week mark in patients 60 years old (p ¼ .006) and patients
with a documentation of neuropathy (p < .001). Patients with dia-
betes but without a history of neuropathy did not have a significant
risk for bone healing at 8 weeks, consistent with the findings from
previous studies (34,35).
A limited blood supply to a thin soft tissue envelope overlying the
medial malleolus puts patients at risk of skin breakdown, exposed
hardware, and infection, especially in high-energy fractures with
compromise to the soft tissue envelope (36,37). Despite the risks of
surgical treatment, conservative treatment for these fractures has
been avoided owing to the high incidence of malunion, nonunion, and
loss of reduction (38). It can be proposed that PSF could be a viable
alternative to standard ORIF for patients at risk of bone and wound
healing complications to limit soft tissue and periosteal stripping.
The present study has demonstrated that fixation of medial mal-
leolar fractures using ORIF was superior to fixation using PSF. ORIF
should remain the treatment of choice for healthy patients free of
bone and wound healing risk factors. With the delayed incidence of
fracture healing associated with PSF in the present study, the option of
PSF as a viable method of fixation of the medial malleolus can now be
questioned.
The present study had several limitations. The radiographic
follow-up in our study was limited to 8 weeks and thus could not
capture the long-term outcomes of fracture healing. The retrospective
nature of the present study also limited data collection to the data
documented in the operative reports and digital radiographs in the
electronic medical records. This introduced variability in terms of the
timing and number of radiographs each treating surgeon ordered
within the 8-week postoperative period. Only a small percentage
(6.5%) of patients underwent PSF, with most (93%) undergoing ORIF.
Also, a potential for selection bias might have been presented when
choosing which patients underwent PSF versus ORIF. Surgeon bias
concerning surgical technique and radiographic interpretation could
also have been a factor. The decision to treat each patient with ORIF
versus PSF was at the discretion of the treating surgeon, which could
have introduced bias because patients treated with PSF could have
been low-demand patients likely to develop wound problems.
In conclusion, the present study has demonstrated that patients
with medial malleolar fractures treated with PSF experience an
increased risk of an unhealed fracture at 8 weeks compared with
patients treated with standard ORIF. The reason for delayed fracture
healing in patients treated with PSF was likely attributed to the high
likelihood of interposed soft tissue in the fracture site, which leads to
poor anatomic reduction.
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