Medial Malleolus Fracture Fixation in the Setting of Concomitant Tibial Shaft Fractures Stephen R. Barchick 1, BA Andrew P. Matson 2, MD Samuel B. Adams 2, MD 1. Duke University School of Medicine, Durham, NC 2. Duke University Health System, Durham, NC
Disclosure The authors have no relevant conflicts of interest to disclose.
Tibial Shaft Fracture with Concomitant Medial Malleolus Fracture The association between posterior malleolus fractures and concomitant tibial shaft (TS) fractures is well-studied, however less is known about medial malleolus (MM) fracture management in setting of concomitant TS fractures. Treatment of TS fractures with plate or intramedullary nail in setting of MM fractures may pose obstacles to standard MM fixation due to hardware that can impede optimal screw placement for fixation. Aim: 1. Report the presentation and management strategies used to treat MM fractures in the setting of concomitant TS fracture
Methods Retrospective Review 7 patients with TS fracture and concomitant MM fractures identified.
Patients Age (y) Height (cm) Weight (kg) Sex Tobacco Use Medical History Mechanism of Injury 1 DM, CAD, Fall From 67.9 152.4 107 F No Tobacco standing (FFS) 2 Motor vehicle 22.4 167.6 83.9 M No accident (MVA) 3 31.9 182.9 83 M No MVA 4 Tobacco Pedestrian vs. 41.0 177.8 79 M Yes vehicle 5 66.8 177.8 118.8 F No Tobacco FFS 6 13.9 182.9 65.5 M Yes MVA 7 29.8 na na F Yes MVA Mean 39.1 173.6 89.5
Fracture Characteristics TS fracture MM fracture Open / Closed Fracture Pattern Fragment Size (mm) Fracture Pattern Displacement (mm) 1 Closed Segmental 29.4 Oblique 0 2 Open Transverse 21.9 Oblique 4.4 3 Open Transverse 14.4 Transverse, Comminuted 5.1 4 Open Transverse 18 Vertical Shear 2.6 5 Closed Distal Spiral 14.3 Transverse 8.5 6 Open Transverse 17.4 Oblique 1.7 7 Closed Transverse 19.1 Transverse 1.4 Mean 19.2 3.3
Simultaneous treatment of TS and MM fractures in 7/7 patients MM Fractures anatomically reduced
Technique: Screw Fixation
Technique: Plate Fixation
Tibial Fixation 1 IMN, distal 2 interlocks, 3 proximal 2 IMN, 1 interlock at each end Medial Malleolus Fixation Method Medial Malleolus # of Screws Screw position relative to nail Complications Screws 1 Anterior none Plate 1 Anterior +posterior none 3 IMN, distal, 2 Screws 2 Medial none interlocks 4 IMN, 1 interlock dis Plate 0 Anterior + Posterior chronic pain 5 Blade plate (previous TKA) Screws 2 n/a superficial wound dehiscence, delayed union of tibia (5.9mos) 6 IMN, 1 interlock Screws 2 Medial none 7 IMN 1 interlock Screws 2 Medial none
Average time to union: 3.12 mos. (1.53-5.93 mos) Complications in 2 patients 1) Superficial wound dehiscence and delayed union 2) Chronic pain
Discussion: MM fixation screws for screw-only or plate fixation can be redirected to accommodate an intramedullary rod in setting of concomitant treatment of MM and TS fractures MM Plate and screw position Distal to nail Screws angled anteriorly, posteriorly, or medially relative to TS hardware
Limitations Selection bias Heterogeneous sample Patients Fracture characteristics Incomplete follow-up Future directions Long term outcomes, Comparative studies, Hybrid implants to address both fractures
References Franceschi F, Franceschetti E, Torre G et al. Tibiotalocalcaneal arthrodesis using an intramedullary nail: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2015:1-10. Thomas RL, Sathe V, Habib SI. The use of intramedullary nails in tibiotalocalcaneal arthrodesis. J Am Acad Orthop Surg. 2012;20(1):1-7. Boer R, Mader K, Pennig D, Verheyen CC. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail. Clin Orthop Relat Res. 2007;463:151-156. Goebel M, Gerdesmeyer L, Mückley T et al. Retrograde intramedullary nailing in tibiotalocalcaneal arthrodesis: a shortterm, prospective study. J Foot Ankle Surg. 2006;45(2):98-106. Moore TJ, Prince R, Pochatko D, Smith JW, Fleming S. Retrograde intramedullary nailing for ankle arthrodesis. Foot Ankle Int. 1995;16(7):433-436. Cooper PS. Complications of ankle and tibiotalocalcaneal arthrodesis. Clin Orthop Relat Res. 2001;391:33-44. Bibbo C, Lee S, Anderson RB, Davis WH. Limb salvage: the infected retrograde tibiotalocalcaneal intramedullary nail. Foot Ankle Int. 2003;24(5): 420-425. Jeong ST, Park HB, Hwang SC, Kim DH, Nam DC. Use of intramedullary nonvascularized fibular graft with external fixation for revisional Charcot ankle fusion: a case report. J Foot Ankle Surg. 2012;51(2):249-253. Mudgal CS, Wilson MG. Revision tibiotalocalcaneal arthrodesis after a failed intramedullary rod: a technique tip. Foot Ankle Int. 1999;20(3):210-211. Guo C, Yan Z, Barfield WR, Hartsock LA. Ankle arthrodesis using anatomically contoured anterior plate. Foot Ankle Int. 2010;31(6):492-498. Mears DC, Gordon RG, Kann SE, Kann JN. Ankle arthrodesis with an anterior tension plate. Clin Orthop Relat Res. 1991;268:70-77. Rowan R, Davey KJ. Ankle arthrodesis using an anterior AO T plate. JBJS-Br. 1999;81:113-117. Brodsky JW, Verschae G, Tenenbaum S. Surgical correction of severe deformity of the ankle and hindfoot by arthrodesis using a compressing retrograde intramedullary nail. Foot Ankle Int. 2014;35(4):360-367.