Sled fixation for horizontal medial malleolus fractures

Horizontal fractures of the medial malleolus occur through exertion of various rotational forces on the ankle, including supination--external rotation, pronation--external rotation, and pronation-abduction. Many methods of fixation are employed for these fractures, but the optimal fixation construct remains unclear.

Horizontal medial malleolus osteotomies were performed in synthetic distal tibiae and randomized into two fixation groups: 1) two parallel unicortical cancellous screws or 2) medial malleolar sled fixation. Specimens were subjected to offset axial tension loading and tracked using high-resolution video. Clinical failure was defined as 2mm of articular displacement.

There were statistically significant increases in mean stiffness (127% higher, P=0.0007) and mean force to clinical failure (52% higher, P=0.0002) with the medial malleolar sled. The mean stiffness in offset tension loading was 232 (SD 83) N/mm for medial malleolar sled and 102 (SD 20) N/mm for parallel unicortical cancellous screws. The mean force to clinical failure was 595 (SD 112) N for medial malleolar sled and 392 (SD 34) N for unicortical screws. In addition, the medial malleolar sled demonstrated elastic recoil to pre-testing alignment while the unicortical screws did not.

Medial malleolar sled fixation was significantly stiffer and required more force to clinical failure than parallel unicortical cancellous screws. A medial malleolar sled requires more dissection to apply surgically, but provides significantly more initial fixation strength. Additionally, a medial malleolar sled acts like a tension band in its ability to capture comminuted fragments while being low profile enough to minimize soft tissue irritation.