The Effect of Percutaneous Screw Fixation of Lateral Malleolus on Ankle Fracture Healing and Function

doi:10.4236/ss.2013.48072

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Surgical Science, 2013, 4, 365-370

http://dx.doi.org/10.4236/ss.2013.48072 Published Online August 2013 (http://www.scirp.org/journal/ss)

The Effect of Percutaneous Screw Fixation of Lateral

Malleolus on Ankle Fracture Healing and Function

Girgis Latif1, Hayder Al-Saadi1*, Medhat Zekry2, Malallah Ali Hassan1, Jamal Al Mulla1

1Rashid Hospital and Trauma Center, Dubai, UAE

2Heart of England NHS Foundation Trust, Bimingham, UK

Email: *[email protected], *[email protected]

Received June 8, 2013; revised July 10, 2013; accepted July 19, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Purpose: To measure the effectiveness of using percutaneous intramedullary screw fixation of the lateral malleolus

fracture on the healing and functional outcome of ankle fracture. Materials and Methods: Forty-six patients with We-

ber A and low Weber B displaced lateral malleolus fractures who underwent closed reduction and percutaneous internal

fixation with an intramedullary, fully threaded, screw were retrospectively reviewed. A 3.5-mm, fully threaded, self-

tapping bone screw (stainless steel from Pelvic Set Synthes). The length of the screw varies between 100 mm and 120

mm, depending on th e fracture lo cation and pa ttern. Results: All fractures united w ithin an averag e time to union of 8.2

weeks. In all patients the average time to full weight bearing was 6.8 weeks, whereas that in patients with isolated lat-

eral malleolus fractures was 4.5 weeks. There were no deep wound infections or complaints of painful hardware. At

latest follow-up, functional results were excellent in, 25 patients (54.3%) good in 20 (43.5%), fair in (2.2%). Conclu-

sion: If reduction of the lateral malleolus fracture can be obtained in a closed fashion (with the aid of an image x-ray

intensifier), we believe that fixatio n may be performed with an axial screw percutaneously. This technique is quick, safe

and easy to do with less complication.

Keywords: Ankle Fracture; Lateral Malleolus; Intramedullary Screw

1. Introduction

Restoring the normal anatomy of the lateral malleolus

has been recognized as the key to operative treatment of

ankle fractures [1]. Yablon pointed out that the talus

faithfully follows the lateral malleolus, and Harper

showed that relatively minor lateral malleolus fractures

allow for talar shaft and joint incongruity [1,2]. The

treatment options for lateral malleolar fractures are either

non operative or operative including; cerclage wiring, lag

screws, a plate and screws, a hook plate, tension band

wiring, axial pins, and axial screws [1-3]. Recently,

Acumed nail introduced to fix the fibular fracture [4]. In

1963, the AO group introduced their well-known meth-

ods of fixation principles like buttress plate and screws

and/or a lag screw, depending on the fracture pattern.

These methods provide stable anatomic fixation and re-

sults of numerous clinical studies are ex cellent [3,5,6].

It has been criticized by several authors because of the

small amount of overlying soft tissues laterally and pa-

tients’ complaints of pain over prominent hardware [7-9].

Among the different methods of fixing lateral malleo-

lus as an intramedullaryfixations using Steinmann pins

[10] and Rush rods [11], however, apprehension about

the hardware backi ng out has limited their usefulnes s.

Cancellous screws alone have also been used for fixa-

tion of Weber A fibula fractures [11,12], but, as with

smooth pins, these fixation devices may allow rotation of

the distal fragment. Several authors have described fixa-

tion of fibular fractures with an axial screw [14,15].

At our institution which is Level-One Trauma Centre

and Tertiary centre for Trauma in Dubai, UAE, we adop t

internal fixation policy of simple Weber A and low We-

ber B fibular fractures with a long intramedullary screw.

It has been utilized b ecause it is felt that this technique is

simpler than buttress plating and with less hardware

complications. The long intramedullary screw also al-

lows better purchase within the fibular canal than a

smooth pin (while accommodating the distal fibular lat-

eral bow), therefore eliminating hardware migration [5].

Furthermore, Bankston et al. demonstrated biomechani-

cally that this particular fixation device was superior in

strength, although not statistically followed up compared

*Corresponding a uthor.

G. LATIF ET AL.

366

to other fixations with plate and screws [16]. They re-

ported their clinical results using open reduction and in-

ternal fixation of lateral malleolus fractures with an in-

tramedullary screw, which demonstrated stable fracture

fixation (allowing early weight bearing) and a 100% rate

of union in their series.

Tamara D. Ray, at all, used intramedullary screw fixa-

tion for lateral malleolus fracture in 24 patients and they

have good results [17].

2. Patients

Between 2006 an d 2012 we retr ospectively rev iewed 280

patients who underwent open reduction and internal fixa-

tion for fractures about the ankle.

Fifty-nine of these patients underwent intramedullary

fixation of a lateral malleolus fracture with an axially

directed screw. Forty-six of these patients were followed-

up for an average of 63.4 weeks. Fracture types included

in this study were 21 lateral malleolus fractures with tear

of the deltoid ligament, 15 bimalleolar fractures, and 10

trimalleolar fractures. Hospital and clinic records were

reviewed for evidence of early or late complications re-

lating to the wound, hardware, reduction, and union. Any

medial ankle surgery for open reduction and internal

fixation of a medial malleolus fracture or repair of a del-

toid ligament was also differentiated. Surgeon’s opera-

tion notes records were also evaluated for length of im-

mobilization, time to full weight bearing, and to tal length

of follow-up. Patients’ subjective findings at the time of

last clinic visit were also documented. New patients were

evaluated for anatomic healing and not for long term

results related to degenerative arthritis. Of the 46 patients

available for follow-up, 16 were female and 30 were

male. Their average age was 39.5 years (range 18 - 67).

Twenty one fractures were isolated lateral malleolus

fractures, of which six had an open deltoid ligament re-

pair in addition to open reduction and internal fixation of

the lateral malleolus. Twenty-five patients had a medial

malleolus fracture, with 15 of these being bimalleolar

and 10 being trimalleolar. Thirty-six fractures were clas-

sified as Weber B and 10 as Weber A. Allmedial mal-

leolus fractures were fixed with one or two cancellous

screws. No poste rior malleolar fractures required fixa-

tion in this group. (Figures 1-3 showing examples of

lateral malleolus fracture fixed by intramedullary screw

done in Rashid Hospital and Trauma Center).

3. Surgical Technique

To be amenable to fixation with an intramedullary screw,

a lateral malleolus fracture must be simple or minimally

comminuted because intramedullary fixation will not

reliably maintain length in comminu ted fractures. Ideally,

the lateral malleolus fracture should be of a transverse or

short oblique configuration. The technique involves us

(a) (b)

Figure 1. (a) and (b): Pre-operative X-Rays; (c) and (d):

Post-operative X-Rays.

ing image intensification to aid anatomic reduction by

inverting the foot and then achieving and maintaining

fracture reduction with a towel clippe r cutaneously (This

technique may be more difficult in a markedly obese or

swollen ankle). While the fracture is stabilized, a stab

incision is made just distal to the tip of the lateral mal-

leolus, and a hole is made in the tip of the lateral malleo-

lus with a 2.5-mm drill bit trying to be somewhat poste-

rior on the lateral malleolus tip (avoid an terior insertion).

A 3.5-mm, fully threaded, self-tapping bone screw

(stainless steel from Pelvic Set Synthes) is then passed

across the fracture site and into the proximal fibular

fragment .The screw is tightened until its head reaches

the bone. It is not possible to make more compression at

the fracture site by further tightening of the screw be

cause it is a fully threaded screw and serrations are on

both sides of fracture site. Electric power drill can be

G. LATIF ET AL. 367

(a) (b)

(e) (f)

Figure 2. (a) and (b): Pre-operative X-rays; (c) and (d):

Post-operative X-rays; (e) and (f): Follow up X-ray after

four months showing good healing.

used to insert the screw to give the screw the enough

power to be bent with the long axis of distal fibula. The

length of the screw varies between 100 mm an d 120 mm,

depending on the fracture location and pattern. When a

medial malleolus fracture is present, a separate incision is

made for open reduction of this fracture before lateral

malleolar fixation and the lateral malleolus is then fixed.

Intraoperative roentgenograms (AP, lateral, mortise, and

stress views) are always obtained to confirm the reduc-

tion of the fracture, the position of the screw, and the

stability of the syndesmosis. The wound is then closed

(a) (b)

(e) (f)

Figure 3. (a) and (b): Pre-operative X-rays; (c) and (d):

Post-operative X-rays; (e) and (f): Follow up X-ray after

one year showing good healing.

with one interrupted suture and gauze dressing with no

cast used in these patients, and the time of non-weight

bearing mobilization varies according to the fracture pat-

tern and associated injuries. Using this percutaneous tech-

nique, the use of a tourniquet is optional. Figure 4

showing the difference in surgical approach between

G. LATIF ET AL.

368

plate fixation and intramedullary screw fixation.

4. Results

The mechanisms of injury (Table 1) in the 46 patients

included in this study were falls (43.5%), motor vehicle

accidents (34.8%), motorcycle crashes (13%), and direct

blows (8.7%). Evaluation of immediate postoperative

roentgenograms for adequacy of reduction (Table 2)

revealed a good reduction in 43 of 46 (93.5%) patien ts, a

fair reduction in 3 of 46 (6.5%) patients, (Table 3). Re-

duction obtained in the operating room was maintained

(a)

(b)

Figure 4. (a) Clinical picture showing the surgical wound

needed for plate and screw fixation of lateral malleolus; (b)

Clinical picture showing the surgical wound needed for

Intramedullary screw fixation of lateral malleolus.

Table 1. Mechanism of injury.

Mechanism Number of Patients Percentage

Fall 20 43.5

Motor vehicle 16 34.8

Motorcycle 6 13

Direct blow 4 8.7

Total 46

Table 2. Radiographic criteria.

Good Fibula out to length

<2 mm of posterior displacement

<1 mm increase in medial clear space

Fair Fibula shortened < 2 mm

2 - 4 mm of posterior displacement

1 - 3 mm increase in medial clear space

Poor Fibula shortened > 2 mm

>4 mm of posterior displacement

> 3 mm increase in medial clear space

Table 3. Reduction on roentgenography.

Rating Number of Patients Percentage

Good 43 93.5

Fair 3 6.5

Poor 0 0

Total 46

in all of the patients who could be followed for 6 weeks

or longer (46 patients). In the 26 patients who were fol-

lowed to the time of fracture union, the average time to

union wa s 8.2 weeks.

Duration of non-weight bearing mobilization varied

from 6 to 10 weeks, with an average of 8.8 weeks. Time

to full weight bearing ranged from 3 to 12 weeks, with an

average time to full weight bearing of 7.2 weeks. There

was a 100% rate of union for all lateral malleolus frac-

tures in this group.

No deep wound infections occurred. No patient has

complained of tenderness or prominence of the hardware,

and no patient has complained of impingement symp-

toms.

A functional rating scale (Table 4) was used to sub-

jectively evaluate ankles in the patients who continued

with clinic appointments or could be contacted by phone.

Of these patients (Table 5), 25 patients (54.3%) had an

excellent result and 20 (43.5%) were considered to have

a good result. One patient (2.2%) who had a fair func-

tional rating had a shortened lateral malleo lus (2 mm).

Patients were evaluated for anatomic healing and not

for long-term results related to degenerative arthritis.

5. Discussions

The importance of stable, anatomic fixation of the lateral

malleolus fragment is highly appreciated to achieve sat-

isfactory results in ankle fractures. Various methods of

lateral malleolar fixation have been utilized, all with ac

G. LATIF ET AL. 369

Table 4. Functional rating (compar e d with normal ankle).

Excellent Normal ran g e o f m ot i o n w i thout pain or stiffness

and return to previous activity level

Good Normal range of motion without stiffness, return to previous

activity level with only occasional pain following activity

Fair Decreased range of motion, frequent pain following activity

Poor Decreased range of motion, pain and stiffness at rest

Table 5. Functional results.

Rating Number of Patients Percentage

Excellent 25 54.3

Good 20 43.5

Fair 1 2.2

Poor 0 0

Total 46

ceptable results. The most common method of fixation of

lateral malleolar fractures is the buttress plating. It pro-

vides stable fixation and maintains length of the lateral

malleolus.It is preferred in cases where the malleolus is

comminuted, as length could not be reliably maintained

with an IM screw, in compound fractures and fractures

with syndesmotic injury where syndesmotic screw needed

(Weber type C). The complications of plate fixation of the

lateral malleolus are wound healing, especially in swol-

len ankles and painful, prominent hardware often de-

velop late.

Schaffer and Manoli [10] realized that lateral hardware

could lead to wound problems and they evaluated the

technique described by Weber in which a buttress plate is

placed posteriorly on the lateral malleolus. They de-

scribed this as the “anti-glide” technique [10]. They per-

formed biomechanical studies and demonstrated that this

method of fixation was more stable than a laterally

placed plate and lag screw. However, this technique is

more demanding in that the surgical dissection posteri-

orly is difficult. Also, the hardware is left in con tact with

the peroneal tendons, which could cause irritation and

pain.

Covino et al. [18] (in their retrospective clinical re-

view and a biomechanical evaluation of lateral malleolus

fixation) they noted no significant difference between

interfragmentary versus plate fixation. They believed

interfragmentary fixation avoided possible complications

of lateral hardware and eliminated the possibility of

screw penetration into the ankle joint. Intramedullary

fixation of lateral malleolus fractures provides stable

fixation without prominent subcutaneous hardware. The

Intramedullary position of the hardware reduces torque

and bending moment on the device. Intramedullary fixa-

tion of weight bearing long bone fractures has largely

replaced compression plating because of these biome-

chanical advantages. The advantages are also evident in

the treatment of non-comminuted lateral malleolus frac-

tures, and the technique should be utilized in indicated

cases. Intramedullary fixation provides stable fixation,

allowing early mobilization in this series.

Bankston, et al. [16] they found the Intramedullary

screw provided 66.5% of the strength of native bone

compared to the lateral buttress plate provided 61.5%.

This was not statistically significant, but it did prove that

an Intramedullary screw provides stable fixation, thereb y

assuring that rehabilitation can be institu ted early without

the risk of loss of reduction.

If reduction of the fracture can be achieved in a closed

fashion (with the aid of image intensification), we be-

lieve that fixation of a lateral malleolus fracture may be

performed with an axial Intramedullary screw percuta-

neously. Our closed technique utilizes minimal soft-tis-

sue dissection, thus decreasing the incidence of wound

complications and painful hardware sites that are occa-

sionally observed after open reduction and plating tech-

niques. Other advantages include improved healing and

shortened rehabilitation time because the fracture hema-

toma is not violated. We have initially selected only

transverse or short oblique fractures as the primary can-

didates for this percutaneous technique. However, as our

experience grows, perhaps other fracture configurations

can also be treated by this method. Nevertheless, if an

acceptable reduction cannot be achieved using this closed

technique, one can and should proceed with open reduce-

tion and internal fixation without hesitation and without

anything lost in th e process.

Our protocol may be improved upon in several areas.

First of all, a prospective, randomized study comparing

this percutaneous method of lateral malleolus fixation

with open reduction and internal fixation with the axial

screw, as well as with that of standard AO technique

should be performed. The unstable lateral malleolus

should be the only type of fracture included in subse-

quent investigations so that accurate conclusions may be

drawn. To properly conduct this research, the number of

patients should be increased and a longer follow-up pe-

riod would be mandatory. Finally, use of more rigid sub-

jective and objective criteria would allow more specific

conclusions to be drawn about the patients’ long-term

functional results.

6. Conclusion

Intramedullary screw fixation of lateral malleolus re-

quires minimal soft-tissue dissection, thereby decreasing

wound complications and painful hardware sites that are

occasionally observed after open techniques. This closed

G. LATIF ET AL.

370

technique also eliminates screw penetration of the ankle

joint and damage to the peroneal tendons, which can be

risks when a plate or lag screws are employed as internal

fixation. Surgical time is also reduced and tourniquet use

is optional. If an acceptable reduction cannot be obtained

using this technique, open reduction and internal fixation

should b e p erformed.

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