From the Research
Tension band wiring (TBW) is a suitable surgical procedure for fracture medial malleolus, but the most recent and highest quality study recommends headless compression screw fixation as a beneficial alternative to conventional methods, including TBW, due to its excellent clinical outcomes and low complication rates 1.
Procedure Overview
The procedure for fracture medial malleolus using TBW involves several steps:
- Patient positioning in supine position with a bump under the ipsilateral hip for better exposure
- Medial longitudinal incision over the medial malleolus
- Fracture site exposure by careful dissection while protecting the saphenous vein and nerve
- Fracture hematoma evacuation and fracture surface cleaning and reduction using reduction forceps
- Insertion of two parallel K-wires from the fracture site proximally into the tibia
- Passing a stainless steel wire through a transverse drill hole made 3-4cm proximal to the fracture site
- Tightening the wire to create compression across the fracture
- Bending and cutting the K-wires to prevent soft tissue irritation
- Confirming fracture reduction and hardware position with fluoroscopy
- Layered closure with absorbable sutures and a well-padded posterior splint application
Key Considerations
- The choice of fixation technique depends on the fracture configuration and clinical scenario 2
- Headless compression screw fixation has been shown to provide excellent stability and clinical outcomes, with low complication rates and no requirement for hardware removal in most cases 1
- The procedure should be performed with careful attention to detail and consideration of the patient's individual needs and characteristics
- Post-operative care involves non-weight bearing for 6 weeks, followed by progressive weight bearing as fracture healing progresses
Comparison of Fixation Techniques
- A systematic review of treatment outcomes for isolated medial malleolar fractures found that conservative treatment may be safe for fractures with displacement ≤2 mm, but further research is needed to compare surgical and conservative treatment for fractures with displacement >2 mm 3
- A biomechanical study found that bicortical screw fixation was the stiffest construct under tension loading conditions, while tension-band fixation using stainless steel wire was stiffer than FiberWire construct 4
- A clinical evaluation of alternative fixation techniques found that headless compression screws provided effective compression and good clinical outcomes, with low complication rates and no cases of non-union 5