Comparison of open reduction and internal

fixation versus closed reduction and

percutaneous fixation for medial malleolus
fractures

Stephen R. Barchick1, BA
Andrew P. Matson2, MD
Samuel B. Adams2, MD

1. Duke University School of Medicine, Durham, NC

2. Duke University Health System, Durham, NC

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 Disclosure
The authors have no relevant conflicts of interest to
disclose.

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 Medial Malleolus Fracture Fixation
Standard accepted techniques for medial malleolus (MM)
fracture fixation involve open reduction and internal fixation
(ORIF)

ORIF for MM fractures may entail significant risk of specific

complications such as wound complication and infection

Data comparing closed reduction and percutaneous fixation

(CRPF) to traditional ORIF is lacking

Aim:
Compare two groups of patients with MM fractures treated
ORIF versus CRPF Duke University Medical Center
 Medial Malleolus Fracture Fixation
Methods

Retrospective case series

490 patients identified with MM fractures managed with
internal fixation over a four year span.

Exclusion Factors
Pilon Fx, ipsilateral tibial shaft Fx, pathologic Fx
Patients < 18 years old
Lack of clinical/radiographic data

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 Medial Malleolus Fracture Fixation

184 patients included in study

ORIF – 144
CRPF - 40

Injury pattern assessed on injury radiographs based on

Orthopaedic Trauma Association (OTA) fracture classification.

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 Medial Malleolus Fracture Fixation
Clinical Course
All surgeries performed at academic tertiary care center in standard
manner by 5 fellowship-trained attending surgeons
All surgeons performed ORIF and CRPF techniques
ORIF
incision over fracture, AO technique for fixation with screws only,
buttress plate or tension band construct

CRPF
No incision, reduction clamp applied percutaneously,
fluoroscopically guided placement of cannulated partially
threaded screws

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 Medial Malleolus Fracture Fixation
Clinical Course
2 week, 6 week, 3 month, 6 month postoperative visits
2 weeks
remove sutures, short leg casts, non-weight bearing (NWB)
6 weeks
remove cast, weight-bearing as tolerated in CAM boot
extension of NWB time period (by 2-6 weeks)
concern for delayed union, diabetes, mobility
concerns, syndesmotic injuries

Radiographs
Interpreted by treating clinician and musculoskeletal
radiologist at time of surgery, and 2 independent researchers
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 Medial Malleolus Fracture Fixation
Data Collection
Fracture union definition
Resolution of fracture line on radiograph
Painless weight-bearing
Zero-to-minimal tenderness to palpation over fracture site

Malunion definition
≥ 2mm of articular surface step-off observed radiographically after fracture
united

Statistical Analysis
Chi-square test for proportions, Student T-test for averages with normal
distribution or Wilcoxon-rank-sum for averages non-normal distribution.
Alpha-level of 0.05 was the standard cut-off.

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 Medial Malleolus Fracture Fixation
Radiographic Measurements

Solid line: articular surface

displacement

Dotted line: MM fracture

fragment length

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 Results
Patient Factors Percutaneous Open p-value
40 144
Male Gender (%) 13 (32) 63 (44) 0.20
Age (years) 55 (18-84) 48 (18-89) 0.03
Body Mass Index (kg/m2) 29 ± 6 30 ± 7 0.11
Diabetes Mellitus (%) 5 (12) 23 (16) 0.59
Peripheral vascular disease (%) 4 (10) 10 (7) 0.52
Tobacco usage (%) 4 (10) 24 (17) 0.30
Injury Factors
High-energy mechanism (%) 10 (25) 33 (23) 0.78
Fibula fracture (%) 34 (85) 113 (78) 0.57
Open fracture (%) 9 (22) 10 (7) <0.01
Transverse fracture (%) 31 (78) 105 (73) 0.56
Fragment size (mm) 17 ± 5 17 ± 5 0.73
Fragment displacement (mm) 10 ± 10 8 ± 8 0.16
Comminution (%) 5 (12) 42 (29) 0.03
Definitive management delay (days) 14 ± 9 14 ± 10 0.85
**Value given is raw number with percentage in parentheses, mean ± standard deviation, or
median with range in parenthesis. Statistically significant values are in bold and italicized. **
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 Results
Outcome Percutaneous Open p-value
Follow-up (weeks) 46 (13-140) 45 (13-222) 0.99
Anatomic reduction (%) 36 (90) 133 (92) 0.63
Time to union (weeks) 10 ± 4 10 ± 11 0.75
Nonunion (%) 1 (2) 5 (3) 0.76
Malunion (%) 4 (10) 7 (5) 0.22
Removal of hardware (%) 3 (8) 20 (14) 0.30
Wound complication (%) 0 (0) 6 (4) 0.95

**Value given is raw number with percentage in parentheses, mean ± standard deviation, or
median with range in parenthesis. Statistically significant values are in bold and italicized. **

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Medial Malleolus Fracture Fixation
Case Example #1: CRPF
Anterior posterior and oblique
radiographs of a 46-year-old male
who sustained a twisting injury and
underwent CRPF (left) of an isolated
MM fracture.
(Left) At 3 months postoperatively the
fracture had fully healed.

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 Medial Malleolus Fracture Fixation
Case Example #2: CRPF malunion
Anterior posterior radiograph (left) of a 72-year-old woman with diabetes and
peripheral vascular disease who was in a motor vehicle collision and
sustained a bimalleolar ankle fracture.

Though reduction
appeared acceptable at
the time of percutaneous
fixation, she went on to
develop malunion of the
MM fracture as seen on
radiographs at four
months postoperatively
(right)

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Medial Malleolus Fracture Fixation
Case Example #3: ORIF nonunion

Anterior posterior and oblique

radiographs of a 37-year-old male
smoker who was in a motor vehicle
collision and sustained a
bimalleolar ankle fracture (left).

He underwent ORIF (left), however

went on to develop nonunion as
seen on radiographs at seven
months postoperatively (right).

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 Medial Malleolus Fracture Fixation
Discussion

Compared to patients who underwent traditional ORIF, those who

underwent CRPF were older and more often had open fractures and
had less fracture comminution

No statistically significant different in outcomes, particularly

nonunion or malunion, between two treatment groups

Non-union, a rare complication (3.0%) of patients overall without

significant variation between CRPF (n=1) and ORIF (n=4)

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 Medial Malleolus Fracture Fixation
Discussion

Removal of hardware was performed at a lower rate in CRPF group

(6.5%) v. ORIF (12.7%), though this difference was not statistically
significant

Medial wound complication rate for ORIF was 3.0%, and 0% for
CRPF, though this difference was not statistically significant
Previous studies wound complication rate- 4-22%.

Screw selection
Partially threaded vs. fully threaded

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 Medial Malleolus Fracture Fixation
Limitations
Selection bias
Small sample size relative to outcome of interest (nonunion)
Poorly controlled treatment groups

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 Medial Malleolus Fracture Fixation
Conclusion
CRPF and ORIF resulted in acceptable radiographic
outcomes and low complication rates for surgical
management of medial malleolar fractures

CRPF may be an appropriate option for simple fracture

patterns in patients where there is or has been a threat to
the soft tissue envelope.

Further, prospective data is needed to evaluate and validate

the efficacy of CRPF given the concern for inadequate
fracture debridement and reduction.

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