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Percutaneous Lag Screw Fixation for Lateral Malleolar Fracture: Technique Description and Case Report | OMICS International
ISSN: 2167-1222
Journal of Trauma & Treatment
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Percutaneous Lag Screw Fixation for Lateral Malleolar Fracture: Technique Description and Case Report

Robinson Esteves Santos Pires1*, Daniel Balbachevsky2, Daniel Baumfeld3, Pedro José Labronici4, Tiago Soares Baumfeld5, Marcelo Back Sternick3 and Fernando Baldy dos Reis2
1Federal University of Minas Gerais, Felício Rocho Hospital, Belo Horizonte (MG), Brazil
2Federal University of São Paulo, São Paulo (SP), Brazil
3Felício Rocho Hospital, Belo Horizonte (MG) Brazil
4Santa Teresa Hospital, Petrópolis (RJ), Brazil
5Federal University of Ouro Preto, Ouro Preto (MG), Brazil
Corresponding Author : Robinson Esteves Santos Pires
Federal University of Minas Gerais, Felício Rocho Hospital
Avenida do Contorno 9530 Barro Preto
Belo Horizonte (MG), Brazil
E-mail: [email protected]
Received November 16, 2012; Accepted December 10, 2012; Published December 12, 2012
Citation: Pires RES, Balbachevsky D, Baumfeld D, Labronici PJ, Baumfeld TS, et al. (2012) Percutaneous Lag Screw Fixation for Lateral Malleolar Fracture: Technique Description and Case Report. J Trauma Treat 1:154. doi:10.4172/2167-1222.1000154
Copyright: © 2012 Pires RES, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Open reduction and internal fixation with plate and screws is the standard treatment for displaced or unstable lateral malleolar fractures. Despite functional satisfactory results obtained using this technique, complications including infection, skin necrosis, and discomfort caused by the plate are reported in 10-20% of cases. Several minimally invasive techniques have emerged as alternatives to avoid these complications. The present study aims to describe a technique and case report for percutaneous treatment of lateral malleolar fractures applying only screw fixation.

Ankle fracture; Lateral malleolus fracture; Fracture; Percutaneous fixation; Screw fixation
MIPPO: Minimally Invasive Percutaneous Plate Osteosynthesis; AOFAS: American Orthopaedic Foot and Ankle Society; AO: Arbeitsgemeinschaft für Osteosynthesefragen
Lateral malleolar fractures are common injuries, and their treatment is familiar to the orthopedic surgeon. Open reduction and internal fixation is the most common method of treatment for displaced fractures [1-8]. However, open reduction can cause soft tissue damage which may affect treatment outcome. Complication rates such as infection and skin necrosis can reach up to 20% [9].
Some authors have demonstrated surgical techniques aiming for a more biological fixation with minimally invasive approach for lateral malleolar fractures. These techniques include retrograde intramedullary fixation with wires, screws, or intramedullary nails; cerclage with steel wires complemented with screws; isolated lag screws, tension band, and percutaneous plate with MIPPO (Minimally Invasive Percutaneous Plate Osteosynthesis) technique [2,4,5,7,10-13].
Siegel and Tornetta [12] described the treatment of pronationabduction fracture type with extraperiosteal plate. Their 31-patient series was treated using lateral approach with plate placement over the “periosteal sleeve”, preserving local blood supply. Healing occurred within 10 weeks in all patients.
In a retrospective analysis involving 19 patients undergoing MIPPO technique for lateral malleolar fractures (mean age=54.8 years and mean follow-up=107.5 weeks), Krenk et al. [11] had good fracture reduction without skin complication or infection.
In a retrospective study using the same MIPPO technique in 25 patients, Carlile and Giles [4], also reported no skin complication or infection. The mean patient age was 61.6, and the follow-up was 12 months minimum.
However, even using minimally invasive techniques, the plate may be palpable and cause patient discomfort. Tornetta and Creevy [10] described the fracture treatment of the lateral malleolus using only lag screws to avoid this complication. The technique is performed making a 3 cm incision and inserting two or three lag screws, 1 cm distance between them. In their series of 47 patients, all less than 50 years old; only one patient complained of lateral ankle pain after fracture healing. In the control group (standard technique with plate and screws), this complication was presented in 17% of the patients. All fractures healed with good function and no loss of reduction.
Bajwa and Gantz [8] described the results of 52 patients who were treated with a technique using two, three, or four lag screws interspersed with cerclage using wires. After 14 weeks, all fractures healed without complications. Fracture reduction and osteosynthesis was performed using lateral approach. Screw and wire removal were unnecessary [14,15].
The present study aimed to describe full percutaneous technique treatment of lateral malleolar fractures. Percutaneous reduction was performed using a clamp and lag screw placement without needing open reduction. Thus, soft tissue is preserved with rigid fixation provided by the lag screws, allowing early mobilization.
Inclusion criteria is adults with good bone quality (<50 years) with lateral malleolar fracture with a long oblique line (supination-external rotation-Lauge Hansen-44-B, AO). Comminuted fractures and short oblique or transverse patterns are ineligible. The essential requirement for this technique is percutaneous reduction success, confirmed by radiographic parameter restoration.
Preoperative Planning
The presented case is a nineteen year old patient, who was a victim of motorcycle accident. He had pain, functional disability, edema and ecchymosis around medial and lateral malleolus. Radiographs of the right ankle in anteroposterior and lateral views demonstrated a 44-B2 (AO) fracture type (supination-external rotation ankle fracture - Lauge-Hansen) (Figures 1A and 1B). External rotation stress test showed a medial clear space widening on the AP view, with instability of the fracture (Figures 2A and 2B).
After intravenous infusion of antibiotics, the patient is anesthetized and is placed in supine position on a radiolucent table with a subgluteus pad ipsilaterally to the fractured side. Tourniquet is not necessary to perform this procedure, except when associated with medial malleolus fractures or deltoid ligament injuries that require open intervention. Percutaneous surgery is initiated positioning the fluoroscopy set in AP view. Two 0.5 cm skin incisions are made superiorly and inferiorly to fracture level (Figure 3). A percutaneous clamp is used to perform fracture reduction (Figure 4).
Special attention over the fibular tendons should be given during reduction clamp positioning. An image intensifier is used to verify reduction quality according to radiographic parameters such as fibula rotation, talocrural angle, tibiofibular overlap, ankle Shenton’s line, “dime sign”, and medial clear space. A superolateral new incision (of 0.5 cm) is made in order to place the lag screw perpendicularly to the fracture. Using a soft tissue protector, the 3.5 mm drill is passed only through the superior cortex of the fibula (Figures 5 and 6). A 2.5 mm drill is passed through the inferior cortex of the fibula. The fracture is fixed with a 3.5 mm cortical screw (Figure 7). After that, two additional screws are inserted to provide increased stability (Figure 8). The clamp should only be removed after placement of the second screw. Cotton test is then performed (with the clamp placed percutaneously) to evaluate tibiofibular syndesmosis integrity. Deltoid ligament, syndesmosis, and medial malleolus injuries are treated with conventional techniques. Skin stitches, dressing, and simple bandaging finish the procedure.
Postoperative Management
Postoperatively, the patient is encouraged to mobilize the ankle to preserve range of motion. Partial load is permitted with crutches and total weight bearing is allowed with 6 weeks post surgery.
The fracture healed in 8 weeks. No reduction loss occurred after healing. The patient received 100 points on AOFAS (American Orthopaedic Foot and Ankle Society) score and presented successful aesthetic result after one year follow-up. No lateral pain was reported.
Surgical technique and the postoperative condition with restoration of the radiographic parameters are shown in figures 9-12.
Figure 13 shows the radiographs of the right ankle in AP and lateral views with healing after 10 weeks. Figure 14 shows the surgical
Concerns/Future of Technique
The present study aims to describe a technique and case report for percutaneous treatment of lateral malleolar fractures applying only screw fixation.
The study limitations were: description of only one case (Level IV of evidence) and relatively short follow-up (12 months). Fracture reduction was performed without direct visualization, and based on radiographic parameters. No CT scan was performed to confirm the fracture anatomical reduction. Although the reduction was maintained with early partial load, it can not be said that the immediate support can be encouraged in all patients, since the sample size does not allow this conclusion.
The study strength is describing a minimally invasive procedure that, according to the authors, has yet to be described in the literature as a full percutaneous procedure. This case reports an alternative less invasive technique for lateral malleolar fracture treatment. The study design indicates this procedure only for 44-B (AO) fractures in patients with good bone quality. The procedure is another option to be incorporated in the arsenal of lateral malleolar fracture treatment, especially in high risk of soft tissue complication patients. Finally, to determine the essential treatment benefits, a randomized clinical trial is necessary, comparing this technique with open reduction and internal fixation with plate and screws, currently considered the gold standard.

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