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Nonoperative Treatment of the Medial Malleolus in Bimalleolar and Trimalleolar Ankle Fractures: A Randomized Controlled Trial

Hoelsbrekken, Sigurd Erik MD, PhD; Kaul-Jensen, Kjersti MD; Mørch, Thale MD; Vika, Håvard MD; Clementsen, Torkil MD; Paulsrud, Øyvind MD; Petursson, Gunnar MD; Stiris, Morten MD; Strømsøe, Knut MD, PhD

doi: 10.1097/BOT.0b013e31828e1bb7
Original Article

Objectives: To compare internal fixation with no fixation of the medial malleolus after open reduction and internal fixation of the lateral malleolus and if needed, the posterior malleolus.

Design: Randomized prospective trial.

Setting: Level III trauma center in a metropolitan area.

Patients: One hundred patients with bimalleolar or trimalleolar Orthopaedic Trauma Association type 44 ankle fractures and displacement of the medial malleolus less than 2 mm after open reduction and internal fixation of the lateral component.

Intervention: Internal fixation or nonoperative treatment of the medial malleolus.

Main Outcome Measurements: American Orthopaedic Foot and Ankle Society ankle hind foot score (AOFAS), The Olerud Molander Ankle (OMA) score, and visual analogue pain scale (VAS).

Results: Median follow-up time was 39 months (range: 24–72). There were no significant differences between the 2 groups with respect to OMA (P = 0.91), AOFAS (P = 0.85), VAS (P = 0.85), or development of osteoarthritis (P = 0.22). Reoperation and complication rates were also comparable, but 4 patients treated nonoperatively developed nonunion of the medial malleolus. These patients reported no functional disabilities and presented OMA, AOFAS, and VAS scores better than average.

Conclusions: Our data indicate that nonoperative treatment of minimally displaced fractures of the medial malleolus after operative fixation of the fibula yields satisfactory results. However, long-term follow-up is needed due to increased risk of nonunion and uncertainty regarding the development of posttraumatic arthritis.

Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Department of Orthopedic Surgery, Oslo University Hospital, Aker, Norway.

Reprints: Sigurd Erik Hoelsbrekken, MD, PhD, Department of Orthopedic Surgery, Akershus University Hospital, 1478 Lørenskog, Norway (e-mail:

The authors report no funding or conflicts of interest.

The authors S. E. Hoelsbrekken and K. K. Jensen contributed equally to the work.

The Regional Ethics Committee for Medical Research has approved the present study (REK Helseregion Øst, approval number 224-01077).

Accepted February 07, 2013

© 2013 by Lippincott Williams & Wilkins