Effect of divergent screw fixation in vertical medial malleolus fractures

This study qualified and evaluated the mechanical properties of three different screw orientations used for fixation of vertical shear fractures of the medial malleolus.

Identical vertical osteotomies were created in synthetic distal tibiae using a jig. The specimens were assigned to one of the three fixation groups (n = 8 per group): (1) parallel: two 40 mm length, 4.0 mm diameter screws placed parallel to each other in the transverse plane; (2) convergent: two 40 mm length, 4.0 mm diameter screws placed 25 degree convergent to each other in the transverse plane; and (3) divergent: two 40 mm length, 4.0 mm diameter screws placed 15 degree divergent to each other in the transverse plane. The specimens were tested using offset axial loading at 1 mm/s until 2 mm of displacement.

The average stiffness was 102 N/mm ± 51 N/mm for the parallel group, 109 N/mm ± 37 N/mm for the convergent group, and 185 N/mm ± 73 N/mm for the divergent group. The average stiffness of the divergent group was significantly greater than either the parallel (p < 0.05) or convergent (p < 0.05) groups. The divergent group was 81.4% more stiff than the parallel group and 69.7% more stiff than the convergent group. The average load at 2 mm of displacement was 324 N ± 87 N for the parallel group, 373 N ± 95 N for the convergent group, and 512 N ± 170 N for the divergent group. The average load at failure of the divergent group was significantly (p < 0.05) greater than the parallel groups. The divergent group was required 58.0% more force at 2 mm of displacement than the parallel group and 37.3% more force at 2 mm of displacement than the convergent group.

The use of a divergent screw pattern resulted in a stiffer fixation construct that requires more force for 2 mm of displacement when used to stabilize an osteotomy model of vertical shear medial malleolus fractures.