Medial Malleolar Stress Fractures Research Articles

Postoperative Medial Malleolar Fractures in Total Ankle Replacement are Associated with Medial Malleolar Width and Coronal Alignment

Category: Ankle Arthritis; Ankle Introduction/Purpose: There is limited evidence regarding risk factors for medial malleolar fractures after total ankle arthroplasty (TAA). A previous study showed that patients with medial pain following TAA had significantly thinner (<11mm) medial malleolar width, which has been used as a threshold for placing a prophylactic screw. However, this study included only six patients with pain over the medial malleolus. Other previously reported risk factors include coronal malalignment and poor bone quality. Therefore, this study examined the risk factors of postoperative medial malleolar stress fractures. In addition, we sought to assess the effect of the prophylactic screw placement. We hypothesized that a medial malleolar width <11mm and varus malalignment would be associated with increased fracture risk and that the prophylactic screw placement would be protective. Methods: A case-control study was conducted on 838 patients undergoing primary TAA between 2015 and. TAA revisions, arthrodesis takedowns, and intraoperative medial malleolar fractures were excluded. Demographic and surgical data were obtained. A total of 21 patients with postoperative medial malleolar stress fractures > 4 weeks postoperatively (cases) were identified through radiologic assessment (radiograph, CT, or MRI) and matched to a control group of 129 patients. Radiographic evaluation included pre- and post-TAA tibial coronal alignment, postoperative medial malleolar width at the tibial component, and prophylactic screw fixation. Demographics and radiographic variables were compared between cohorts using the Mann-Whitney U test for continuous variables and Pearson Chi-square for categorical variables. Logistic regression was used to investigate the association of medial malleolar stress fractures with gender, coronal tibial implant size, postoperative coronal alignment, prophylactic screw fixation, and medial malleolar width using odds ratios (OR), and standard error (SE). Results: Of 838 TAAs, 2.51% sustained a postoperative medial malleolar fracture (n = 21). Of these, 13/21 (61.9%) required reoperation: internal fixation (12) and TAA revision (1). Mean (SD) medial malleolar width was significantly smaller in the fracture cohort (8.62 mm [1.63]) than in controls (11.78mm [1.75]), P<0.001). Mean (SD) postoperative tibial component coronal alignment was 92.2º (2.82) for patients with medial malleolar fracture and 90.23º (1.68) for the control cohort (P = 0.003). Postoperative varus tibial component alignment (OR = 1.61 [95%CI 1.16 02 − 2.22], P = 0.004) and smaller medial malleolar width (OR = 0.11 [95% CI 0.04 02 − 0.3], P < 0.001) were associated with increased probability of a post-TAA medial malleolar fracture. Prophylactic screw fixation resulted in a 90% reduction in the odds of a fracture (OR = 0.10 [95%CI 0.02 02 − 0.64], P = 0.015). A medial malleolar width of 10.31 mm was identified as a threshold for predicting a medial malleolar stress fracture. Conclusion: In this study, the prevalence of postoperative periprosthetic fractures after TAA was similar to prior studies. Decreased medial malleolar thickness and postoperative varus malalignment were associated with an increased risk of a postoperative medial malleolar stress fracture. A malleolar width of 10.31 mm was identified as a potential threshold. Prophylactic medial malleolar screw fixation was protective and associated with a 90% reduction in fracture probability. Surgeons should consider prophylactic screw fixation patients with a medial malleolar width < 10.31 mm or at risk of postoperative varus deformity.

Early outcomes and radiographic alignment of the Infinity total ankle replacement with a minimum of two year follow-up data

BackgroundThe Infinity total ankle replacement (Wright Medical Technology, Memphis, TN) is a low profile, fluoroscopically navigated, fixed-bearing device. We hypothesised that the fluoroscopic navigation would allow more accurate alignment of the prosthesis than conventional techniques. We present our minimum two year follow up data of Infinity ankle replacements. MethodsAll total ankle replacements (TARs) performed at our institution were prospectively followed-up with EQ5-D and MOx-FQ scores as well as intra-operative radiation exposure and radiographic alignment data. Post-operative radiographs were used to measure the alignment of the prostheses. We identified 20 implants with minimum of two year follow up which were compared to a control group of 20 Zenith TAR’s (Corin, Cirencester, UK). ResultsIntra-operative fluoroscopic navigation has allowed excellent alignment of all prostheses. Median deviations from 90° alignment to the anatomical axis of the tibia were 1.5° and 1.2° in the anterior-posterior (AP) and lateral planes respectively, compared to 2.8° and 3.1° in the Zenith group. This difference reached significance (p=<0.05) using the Mann–Whitney U test. At 2 years, MOx-FQ scores had fallen from pre-operative mean of 63.9∓17.1 to 15∓12.7. EQ-5D VAS scores had improved from 71.3∓17.3 to 81.4∓9.7 points. Radiation exposure had a mean screening time of 82∓29.4s and a decrease in exposure per patient was observed over time. No patients have undergone, or are awaiting, revision surgery. Complications include one intraoperative medial malleolar tip avulsion fracture, one medial malleolar stress fracture, and one patient who developed CRPS. ConclusionsWe present evidence that this system achieves better anatomical alignment of the components when compared to techniques without fluoroscopic navigation. The implant survival and complication profile at a minimum of two years is satisfactory.

Etiology and Treatment of Delayed-Onset Medial Malleolar Pain Following Total Ankle Arthroplasty.

Total ankle arthroplasty (TAA) has become a successful treatment for end-stage ankle arthritis. Some patients may still have pain or may present with new pain. Suggested sources of medial pain include tibialis posterior tendonitis, impingement, or medial malleolar stress fracture. Etiology and treatment remain unclear. The objective of our study was to evaluate patients with delayed-onset medial malleolar pain following TAA who underwent treatment with percutaneous medial malleolar screw placement and propose an etiology. Patients who had undergone TAA at our institution were reviewed and those with medial malleolar pain were identified. Clinical and radiographic examinations were performed pre- and postoperatively. Radiographs were compared with those from a cohort of controls without a history of medial pain. All affected patients failed conservative therapy and were treated with percutaneous placement of medial malleolar screws positioned from the malleolar tip and extending proximally beyond the tibial component. Postoperatively, patients were placed in an ace wrap and allowed to be weightbearing to tolerance, except for 1 patient initially restricted to partial weightbearing. Visual analog scale (VAS) scores were recorded. Seventy-four (74) patients underwent TAA by the corresponding author. All (100%) were female with an average age of 66 (range, 57-73) years. Average follow-up since screw placement was 21.4 (range, 10-41) months. Six (8.1%) underwent placement of 2 percutaneous medial malleolar screws. Patients presented with pain an average of 12 (range, 4-24) months postoperatively and underwent screw placement an average of 2.8 (range, 1-6) months after presentation. At the time of TAA, none had a coronal plane deformity and none underwent a deltoid ligament release as part of balancing. All (100%) patients had pain and swelling directly over the medial malleolus prior to screw placement. Postoperatively, 1 (17%) had mild pain clinically at this site and 2 (33%) had occasional pain medially with activity. Average VAS scores improved from 5.7 (range, 4-6) preoperatively to 1.3 (range, 0-3) postoperatively (P < .05). Three (50%) patients had a bone density test and all were normal. Prior to screw placement, radiographs demonstrated no signs of stress fracture or misalignment. Average minimum width of the medial malleolus at the level of the tibial component was 10.2 mm (range, 9.2-11.0), which was significantly less (P < .05) than the control group of 19 patients whose distance measured 12.2 mm (range, 8.5-14.8). Patients who present with new-onset medial malleolar pain with normal radiographs following TAA may have medial malleolar insufficiency fracture. These patients can be treated successfully with minimal morbidity by placement of percutaneous medial malleolar screws. Etiology may be related to deltoid traction, subacute stress fracture, and/or impingement of the talus component on the medial malleolus. Medial malleolar pain may be misdiagnosed as tibialis posterior tendonitis, impingement, or implant failure. This diagnosis should be considered in patients who have pain at the medial malleolus, particularly if they are female or have medial malleolus thickness less than 11 mm at the level of the tibial implant. Placement of prophylactic medial malleolar screws may be considered at the time of TAA when these conditions exist. Level IV, case series.

The treatment and outcomes of medial malleolar stress fractures: a systematic review of the literature.

Context:The medial malleolus is considered a high-risk stress fracture and can be debilitating to the highly active or athletic populations. A range of treatment methods have been described with varying outcomes. Currently, there is no gold standard treatment option with optimal results described.Objective:A systematic search of the literature to determine treatment options and outcomes in medial malleolus stress fractures.Data Sources:OVID/Medline, EMBASE, and the Cochrane Library from 1950 to September 2013.Study Selection:Included studies mentioned treatment and outcomes of medial malleolus stress fractures.Study Design:Systematic review.Level of Evidence:Level 4.Data Extraction:The searches used combinations of the terms stress fracture, medial malleolus, management, and treatment. Two authors independently reviewed the selected articles and created individual tables, which were later compiled into a master table for final analysis.Results:Six retrospective case series were identified (n = 31 patients). Eighty percent (25/31) of patients were men, with an average age of 24.5 years. Ninety percent (28/31) of patients were at least involved in recreational athletics. All patients were able to return to sport. Complications were seen in both groups ranging from minor stiffness to nonunion requiring open reduction internal fixation.Conclusion:Nonoperative and operative interventions have proven to be successful with regard to healing and return to play for medial malleolar stress fractures in the recreational and competitive athlete. However, early operative intervention can possibly create a higher likelihood of early healing, decrease in symptoms, and return to play.

Medial Malleolar Stress Fracture in Athletes: Diagnosis and Operative Treatment

Stress fractures are common overuse injuries in athletes. Medial malleolar stress fractures are rare but they have an important clinical relevance because of their tendency to cause considerable disability and loss of time in sports without proper treatment. The diagnosis of medial malleolar stress fracture is often a challenge and it is therefore often delayed which may cause even further problems in the treatment. The purpose of this study was to increase the awareness of medial malleolar stress fractures as a possible cause for medial ankle pain and to stress the importance of MRI in the diagnostics as well as to evaluate the results of surgical treatment. Between 1995 and 2008, a total of ten athletes with a medial malleolar stress fracture were operated at our centre. All operated cases during those years were included in the study. The cases were retrospectively analyzed. Return to pre-injury level of sport was evaluated and considered as an indicator of successful treatment. Initially all standard radiographs were negative whereas in MRI the fractures were all visible. After operative treatment all medial malleolar stress fractures healed clinically in three to four months and all except one of the athletes were able to return to their pre-injury level of sports. Early MRI is recommended if a medial malleolar stress fracture is suspected. Surgical treatment seems to result in rapid healing of the fracture and return to sports. In our opinion early surgery should be considered especially in athletes.

Treatment of Medial Malleolar Stress Fractures

The incidence of medial malleolar stress fractures varies from 0.6%-4.1% of all stress fractures. These fractures occur almost entirely in athletes and runners, and more frequently in skeletally mature patients aged 20-40 years. Treatment depends on the result of diagnostic imaging, displacement of the fracture, and demands of the athlete. An aggressive nonoperative protocol of non–weight-bearing cast immobilization (usually for 6 weeks) may be successful if the stress fracture is diagnosed soon after symptoms appear, but time to complete healing and safe return to activity may be as long as 6 months, which is unacceptable for most elite athletes. We recommend surgical treatment of most stress fractures of the medial malleolus, especially for displaced fractures in elite athletes, leading to early recovery and early return to sports activities.

Medial Malleolar Stress Fracture Secondary to Chronic Ankle Impingement

Medial malleolar stress fractures are uncommon even in the sporting population. We believe that stress fractures of the medial malleolus may be the end stage of chronic anteromedial ankle impingement in elite running and jumping athletes. We present five cases of elite athletes who presented to our institution with stress fractures of the medial malleolus over a 3-year period (2004 to 2007). In each case preoperative imaging revealed an anteromedial bony spur on the tibia. All fractures were internally fixed and at the same sitting had arthroscopic debridement of the bony spur. All fractures united without further intervention, average time to union was 10.2 (range, 6 to 16) weeks. At most recent review (average, 18 months; range, 8 to 37 months), all patients had resumed sporting activity to their previous level. No patient had suffered a recurrent fracture of the medial malleolus. We believe this region of impingement to be important in the development of the stress fracture and should be addressed at the time of fracture fixation.

Stress Fractures of the Medial Malleolus

Medial malleolar stress fractures account for only 10% of all stress fractures of the foot and ankle, but they can cause significant disability and loss of participation time, particularly in high-level athletes. They are most common in patients between the ages of 20 and 40 years and occur almost exclusively in athletes involved in sports that involve running and jumping. Medial malleolar stress fractures are considered at high risk for progression to complete fracture, delayed union, or nonunion and often are treated as acute fractures. An aggressive nonoperative protocol of nonweight-bearing cast immobilization (usually for 6 weeks) may be successful if the stress fracture is diagnosed soon after symptoms appear, but time to complete healing and safe return to activity may be as long as 6 to 8 months, an unacceptable solution for most elite athletes. Open reduction and internal fixation with 2 or 3 fully threaded cortical screws generally allow faster healing and return to activity when compared with nonoperative treatment.

Medial Malleolar Stress Fracture in An Intercollegiate Football Player

Medial Malleolar Stress Fracture in An Intercollegiate Football Player

Medial malleolar stress fractures in seven patients: review of the clinical and imaging features.

Stress fractures of the medial malleolus were discovered in seven patients, five male and two female subjects aged 16-34 years. All except one were involved in running and jumping athletic activities. Gradual onset of pain over the medial malleolus occurred with repetitive activity. Focal intense increased uptake in the medial malleolus was present on bone scans. Conventional radiography and computed tomography demonstrated the presence of subtle fissures at the junction of the medial malleolus and the tibial plafond, and well-circumscribed lytic lesions were also seen in three patients. Two patients developed a complete fracture of the medial malleolus. Stress fractures of the medial malleolus should be suspected in patients involved in athletic and/or unusual activities who have experienced persistent and unexplained pain over the medial malleolus. Bone scans and radiographs should be obtained for diagnostic purposes in these patients.