Operative vs Nonoperative Management of Unstable Medial Malleolus Fractures

• DOI: 10.1001/jamanetworkopen.2023.51308
• Publication Date: 2024-01-18T16:00:53Z
• Authors: Thomas H. Carter; William M. Oliver; Katrina R. Bell; Catriona Graham; Andrew D. Duckworth; Timothy O. White
• Keywords: Medial malleolus; Neurovascular bundle; Malleolus; Trauma Center

Importance Unstable ankle fractures are routinely managed operatively. However, because of soft tissue and implant-related complications, recent literature has reported on the nonoperative management well-reduced medial malleolus after fibular stabilization, but with limited evidence supporting routine application. Objective To assess superiority internal fixation (displacement ≤2 mm) compared nonfixation stabilization. Design, Setting, Participants This superiority, pragmatic, parallel, prospective randomized clinical trial was conducted from October 1, 2017, to August 31, 2021. A total 154 adult participants (≥16 years) a closed, unstable bimalleolar or trimalleolar fracture requiring surgery at an academic major trauma center in UK were assessed. Exclusion criteria included injuries no medial-sided fracture, open fractures, neurovascular injury, inability comply follow-up. Data analysis performed July 2022 confirmed September 2023. Interventions Once lateral (and where appropriate, posterior) had been fixed satisfactory intraoperative reduction by operating surgeon, randomly allocated (n = 78) 76) malleolus. Main Outcome Measure Olerud-Molander Ankle Score (OMAS) 1 year randomization (range, 0-100 points, 0 indicating worst possible outcome 100 best outcome). Results Among (mean [SD] age, 56.5 [16.7] years; 119 [77%] female), 144 (94%) completed trial. At year, median OMAS 80.0 (IQR, 60.0-90.0) group 72.5 55.0-90.0) ( P .17). Complication rates comparable. Significantly more patients developed radiographic nonunion (20% vs 0%; < .001), 8 13 clinically asymptomatic; patient required surgical reintervention for this. Fracture type quality appeared influence union outcome. Conclusions Relevance In this comparing nonfixation, not superior according primary 5 although rate manage low, future implications unknown. These results support selective anatomically reduced malleolar Trial Registration ClinicalTrials.gov Identifier: NCT03362229