Percutaneous intramedullary screw solid alternative to neutralization plate for Lateral malleolar fractures

Sherif Hamdy Zawam et al found in the study published in "International Orthopaedics" that - The use of intramedullary screw fixation is an efficient and safe alternative to the classic ORIF methods using neutralization plates in unstable low lateral malleolar fractures. Plate fixation may be more suitable to achieve anatomical reduction. However, percutaneous intramedullary screw fixation is associated with fewer complication rates, especially in wound problems and symptomatic hardware.

Open reduction and internal fixation (ORIF) with plate and screws remains the gold standard for surgical management of lateral malleolar fractures. However, ORIF with plate fixation may lead to several complications especially in old ages, patients with diabetic neuropathy, or patients with poor skin conditions.

Sherif Hamdy Zawam et al conducted a prospective case series study involving 73 patients with fractured lateral malleolus of type A, B according to Weber classification, to whom internal fixation was performed by either lateral plate and screws construct (Group A) or intramedullary screw (Group B). All patients were followed up for 12 months at least, with an average follow up time of 12.7 months.

Surgical technique (Group B):

Under image intensifier guidance, closed reduction was achieved by inverting and internally rotating the foot while traction was applied. Then, reduction was maintained with a percutaneous pointed reduction forceps. A 1–2-cm incision was made from the tip of the lateral malleolus aiming distally and slightly posterior. A 2.5-mm drill bit was used through the distal part (Fig. 4). Then, a 3.5-mm cortical, fully threaded screw with a washer was advanced until the washer reaches the bone (Fig. 5). The screw length varied from 90 to 110 mm.

The reduction was evaluated by post-operative radiographs using Mclennan J.G. and Ungersma scale. Patients attended the clinic after two weeks for sutures removal. Then, all patients were followed both clinically and radiologically at regular visits every two weeks until full union was achieved. A below-knee slab was applied for four weeks before starting ankle range of motion. Partial weight-bearing was allowed after six weeks, and full weight-bearing was initiated when complete union was confirmed clinically and radiologically.

The observations of the study were:

• According to the (AOFAS) score, the mean score for group (A) was 87.11 ± 6.74. It was not significantly different from that in group (B) (86.57 ± 7.17) (P=0.573).

• Functional outcome grading according to the modified Olerud and Molander Score (OMS) system showed no significant difference between both groups (P=0.705). The mean score in group (A) was 87.76 compared to 86.43 in group (B).

• The mean operative time for all cases was 33.7 ± 5.56 minutes. It was significantly less in group (B); the IM screw group (28.66 ± 3.04) min when compared to group (A); the ORIF group (38.34 ± 2.34) min (P<0.001).

• The average size of the incision was significantly less in the intramedullary fixation group (1.9 cm) when compared to the lateral plate group (8.7 cm) (P<0.001).

• A significant difference was present between both groups regarding the average time to full union as it was 9.11 weeks (range 7–16) in group (A) and 8.11 weeks (range 7 to 12) in group (B) (P=0.006).

• There was a relatively higher accuracy of reduction with the plate fixation group, but it was statistically insignificant.

• There was a relatively fewer complication rate with the use of intramedullary screw fixation compared to plate fixation.

The authors recommended using intramedullary screw fixation more often whenever acceptable closed reduction of the fracture can be achieved, in elderly patients and those with chronic co morbidities who are more likely to develop wound complications.

Further reading:

Lateral malleolar fractures Weber Type A and B: does percutaneous intramedullary screw confer a solid alternative to the traditional neutralization plate?

Sherif Hamdy Zawam et al

International Orthopaedics (2022) 46:2127–2134

https://doi.org/10.1007/s00264-022-05425-x