Medoff, R, MD

Abstract, Castle Medical Center, Kailua, Hawaii, USA

Cush, G., M.D., Gibbs, J., M.D.

American Orthopeadic Foot & Ankle Association, 23rd Annual Summer Meeting, July 2007 , 07/01/2007

Cush, G, MD, Campbell, M, MD, Maloney, P, MD, Gibbs, J, MD

AOFAS 25th Annual Meeting, Scientific Poster #98, July 2009

Psychoyios, V.N., Thompa, S, Intzirtzis, P, Mpogiopoulos, A, Zampiakis, E

The Bone & Joint Journal

Abstract: Ankle fractures are among the most common injuries treated by orthopaedic surgeons, and surgical treatment is often required to optimise the results. This retrospective study was undertaken to assess the effectiveness of the TriMed ankle fixation system in the treatment of malleolar fractures.

During in last ten months, fifteen patients with an average age of 63 years uderwent open reduction and internal fixation of a bimalleolar anke fracture with the TriMed fixation system. A standart surgical approach was used for both the medial and lateral malleolus. Regarding the later malleolus, a TriMed Sidewinder plate which requires no additional interfragmentary screw was applied. Based on the morphology of the fracture of the medial malleolus, either interfragmentary screws or the sled-like medial malleolus fixation system was applied. One patient underwent in additional open reduction and internal fixation of the posterior malleolus. All fractures proceeded to uncomplicated union in an average healing time of 6 weeks. Excellent functional restoration of the ankle joing, comparable to the ipsilateral ankle, was achieved. The TriMed ankle fixation system represents a good alternative method in malleolar fracture fixation which simplifies the fracture reduction and obliterates the need for a lag screw, thus preserving the biology of the fracture site. Furthermore, it can be used for the reconstruction of distal fractures of the lateral malleolus. However, further long-term studies are recommended to evaluate the success of the TriMed fixation system.

John D. Hewitt M.D., Craig T Haytmanek M.D., Joshua N. Tennant M.D., Ryan C. May M.S., Selene G. Parekh M.D. MBA

Current Orthopaedic Practice, 22(6), 534–537

Background: Ankle fractures are common injuries and many have indications for operative treatment. Newer plate designs have recently been introduced and have the potential to simplify and shorten the operative procedure. This study compared the cost of operative treatment of a lateral malleolar fracture between a novel plate design and a neutralization plate and lag screw approach.

Methods: A retrospective chart review was performed with institutional review board approval. All patients operatively treated for a Weber B lateral malleolar fracture were divided into two cohorts: an experimental group treated with a novel plate and a control group treated with a lag screw and neutralization plate. Cost of implants, operating room costs, and time of healing were compared between the two cohorts.

Results: The average implant cost for the novel plate design ($1,141) was significantly higher than that of the plate and lag screw construct ($208) (p < 0.0001). The average operating room costs were significantly lower for the experimental group ($4,410) compared to the control group ($6, 037) (p <0.01). The average time to union was significantly less in the experimental group (75 days) than in the control group (97 days) (p < 0.04).

Conclusions: Use of a novel plate design in this study was associated with decreased operating room costs and a quicker time to union compared to the use of a traditional construct. This may result reduced amounts of dissection required to apply the novel plate and a more favorable biological environment for bone healing. The additional cost of new implant designs may be justified by quicker, simpler operative techniques, and enhanced healing.
Level of evidence: Therapeautic Level III

R Adelaar MD, J Wayne, T Patel, JR Owen, W Byrd, R Graves, R Chande, V Mounasamy

 Foot & Ankle International, 34(3), 426–433, Mar 2013

Background: Displaced medial malleolus fractures require surgical repair because of the critical role of the structure plays in normal joint function. Various approached exist, but options are limited for small fragment fractures. This study compared repair with the Medial Malleolar Sled fixation system (TriMed, Inc., Valencia, CA) to lag screws in 2 modes of biomechanical loading in a cadaveric model.

Methods: A Muller type B medial malleolus fracture was simulated on matched pairs of cadaveric lower extremities and repaired with the sled of 2 cancellous lag screws. Tibial distraction (tension, n = 10) or internal rotation (torsion, n = 11) was applied. Fragment movement was measured in the sagittal (tension and torsion) and transverse (torsion-only) planes. Fragment movement at 1 mm and 2 mm (clinical malunion) of gapping during tension and at 2,4,5, and 8, N-m during torsion was analyzed via paired t tests.

Results: In tension, the load at the 2-mm gap was statistically lower for screws (P = 0.026). Opening angle was statistically larger for the sled at the 1-mm (p = 0.0004) and 2-mm (P = 0.008) gap. In torsion, gapping was statistically lower for the sled (ranging from p = 0.0013 at 4 N-m to P = 0.0187 at 8 N-m). No differences were detected for opening angle or transverse plane movement.

Conclusion: The sled appeared stronger in tension and as effective as lag screws in torsion. The sled may be a viable option for fractures too small for 4.0- or 3.5-mm lag screws.

Clinical Relevance: The sled my be suitable in applications where a tension band would normally be considered and may provide stronger fixation in osteoporotic bone compared with lag screw fixation.

Parekh S., Anand P., Glisson R., Eckel T.

Foot Ankle Int, Volume: 34 issue: 11, page(s): 1588-1595

Background: Displaced lateral malleolar fractures are often treated with reduction and surgical stabilization. However, there has not been a comprehensive laboratory comparison to determine the most appropriate device for treating these patients. This study subjected a range of contemporary lateral fibular plates to a series of mechanical tests designed to reveal performance differences.

Methods: Forty fresh frozen lower extremities were divided into 4 groups. A Weber B distal fibula fracture was simulated with an osteotomy and stabilized using 1 of 4 plate systems: a standard Synthese one-third tubular plate with an interfragmentary lag screw, a Synthes LCP locking plate with a lag screw, an Orthohelix MaxLock Extreme low-profile locking plate with a lag screw, or a TriMed Sidewinder nonlocking plate. Controlled monotonic bending and cyclic torsional loading were applied and bending stiffness, torsional stiffness, and fracture site motion were quantified. Resistance to cyclic torsional loading was determined by quantifying the number of loads withstood before excessive rotation occurred. Correlation between bone mineral density and each of the mechanical measures was determined.

Results: There was no difference in angulation or bending stiffness between plates. All plates except the LCP showed greater lateral deflection than in the other bending directions. Bending stiffness was lowest in lateral distal fragment deflection for all 4 plates. There was a positive correlation between bone mineral density and bending stiffness for all plate types. There was no difference in fracture site rotation between plate types in internal or external torsion, but internal rotation for the distal fragment consistently exceeded external rotation. Torsional stiffness in external rotation exceeded stiffness in internal rotation in nearly all specimens. LCP plates performed relatively poorly under cyclic torsion.

Conclusions: Significant differences in plate performance were not demonstrated. The effects of bone quality variability and differences in interfragmentary screw purchase resulted in data dispersion that confounded the absolute ranking of plate performance.

Clinical Relevance: Identification of an optimal lateral fibular plating system has the potential to improve the clinical outcome of malleolar fracture fixation, particularly when patient conditions are unfavorable.

Cush G. MD, Irgit K. MD, Richard R. MD, Rutter M. MD

AOFAS Annual Meeting 2013, Hollywood FL; e-Poster Presentation

Rutter M, Richard R, Irgrit K, Cush G

Techniques in Foot & Ankle Surgery, 14(2), 94–98, June 2015 

Background: To examine outcomes of open reduction internal fixation (ORIF) of patients with medial malleolar fractures that were fixed using a wire-form fixation device. We hypothesize that patients who undergo operative intervention using the wire-form fixation device can expect union rates, clinical and functional outcomes comparable to those of other methods of fixation.

Methods: A retrospective review was conducted of all patients with medial malleolar fractures who underwent ORIF of medial malleolar fracutres from November 2006 to June 2011. Electronic medical records were reviewed for clinical and radiographic outcomes. Medial malleolar fractures were classifed using the Hersovici classification system. Patients were contacted via telephone to complete the American Acadaemy of Orthopaedic Surgeons Foot and Ankle Questionnaire and the Short Musculoskeletal Form Assessment.

Results: A total of 21 patients underwent ORIF of medial malleolar fractures utilizing the wire-form fixation device and 19 met inclusion criteria for this study. There were 18 Herscovici type C (10 transverse, 8 oblique) fractures and 1 class D (vertical) fracture. Ten of the patients were female. Average age was 43 +/- 4 years (range, 20 to 80 years old). Average lenght of follow-up was 48 +/- 3 months (range, 20 to 71 mo). The average time to surgey was 12 +/- days (range, 6 to 19 d). There were no intraoperative complications and all fractures went on to union. In 2 patients the wire-form fixation device caused pain due to irritation. One patient underwent surgery to remove the painful implant and 1 patient desired surgery for device removal during the study. There was 1 case of superficial cellulitis.

Conclusions: The wire-form fixation device provides reliable fixation for ORIF of transverse, oblique, and vertical, medial malleolar fractures. Nonunion, reopration rates, and other complications rates are similar to other medial malleolar fixation methods.

Type of Study / Level of Evidence: Therapeutic – Level IV

Knutsen, A, MS, Sangiorgio, S N, PhD, Lui, C, Zhou, S, BS, Warganich, T, MD, Fleming, J, MD, Harris, T, MD, Ebramzadeh, E, PhD

Foot and Ankle Surgery, 22(4), 278-285., December 2016

Background: The goal of this study was to evaluate the biomechanical performance of three distal fibula fracture fixation implants in a matched pair cadaveric fibula model: (1) a 5-hole compression plate with lag screw, (2) a 5-hole locking plate with lag screw, and (3) the 6-hole tabbed-plate with locking screws.

Methods: Three-dimensional motions between the proximal and distal fibular segments were measured under cyclic valgus bending, cyclic compressive axial loading, and cyclic torsional external-rotation loading. During loading, strains were measured on the surface of each fibular near the simulated fracture site, and on the plate, to assess load transfer. Bone quality was quantified globally for each donor using bone mineral density (BMD) measured using Dual X-Ray absorptiometry (DEXA) and locally at the fracture site using bone mineral content (BMC) measured using peripheral quantitative computed tomography (pQCT).

Results: Mean failure loads were below 0.2 Nm of valgus bending and below 4Nm of external-rotational torque. Mean failure angulation was below 1 degree for valgus bending, and failure rotation was below 7 degrees for external-rotation. In the compression plate group, significant correlations were observed between bone quality (global BMD and local BMC) and strain in every one of the five locations (Pearson correlations coefficients >0.95, p <0.05). In contrast, in the locking and tabbed-plate groups, BMD and BMC correlated with far fewer strain locations.

Conclusions: Overall, the tabbed-plate had similar construct stability and strength to the compression and locking plates. However, the distribution of load with the locking and tabbed-plates was not as heavily dependent on bone quality.