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VOLUME 8 , ISSUE 1 ( June, 2018 ) > List of Articles


Open Ankle Fractures with Loss of the Medial Malleolus: A Case Series on a Rare Injury

Travis Dekker, Anthony Catanzano, Alexander Lampley, Samuel B Adams Jr

Keywords : Bone loss, Medial malleolus, Open ankle fracture, Outcomes.

Citation Information : Dekker T, Catanzano A, Lampley A, Adams Jr SB. Open Ankle Fractures with Loss of the Medial Malleolus: A Case Series on a Rare Injury. The Duke Orthop J 2018; 8 (1):28-32.

DOI: 10.5005/jp-journals-10017-1091

License: CC BY-NC 3.0

Published Online: 01-05-2017

Copyright Statement:  Copyright © 2018; The Author(s).


In patients with particularly high-energy injuries causing open ankle fractures, the medial malleolus can be extruded from the ankle and either lost at the scene of the injury or unable to be fixed at the time of operative intervention. Minimal reporting of this devastating injury exists in the literature. Our study aims to report the outcomes in patients with open ankle fractures and loss of the medial malleolus. We retrospectively reviewed eight patients with this injury pattern over a 14-year span (2000–2014). Two of these patients were treated with below-knee amputation for a mangled extremity. Five of the patients were treated with tibiotalocalcaneal (TTC) arthrodesis. Of the five patients treated with ankle and subtalar arthrodesis, two were treated with open reduction and internal fixation (ORIF) prior to their arthrodesis. The remaining three patients were treated with arthrodesis after their initial surgical treatment with irrigation and debridement (I&D) and external fixation. Four of the six patients required soft tissue coverage with a rotational or free flap. All patients undergoing TTC arthrodesis went on to fusion; at final followup (average 2.7 years; 1.1–8.2 years), they reported minimal pain in the operative extremity and were able to ambulate. We found TTC arthrodesis to be a viable option for patients with this devastating injury. These findings could aid orthopedic surgeons not only in preoperative patient education and prognosis but also in operative planning in patients with this rare injury.

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  1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006 Aug;37(8):691-697.
  2. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures– an increasing problem? Acta Orthop Scand 1998 Feb;69(1):43-47.
  3. Bugler KE, Clement ND, Duckworth AD, White TO, McQueen MM, Court-Brown CM. Open ankle fractures: who gets them and why? Arch Orthop Trauma Surg 2015 Mar;135(3):297-303.
  4. Olerud S, Karlstrom G, Danckwardt-Lilliestrom G. Treatment of open fractures of the tibia and ankle. Clin Orthop Relat Res 1978Oct;136:212-224.
  5. Phillips WA, Schwartz HS, Keller CS, Woodward HR, Rudd WS, Spiegel PG, Laros GS. A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg Am 1985 Jan;67(1):67-78.
  6. Lindenbaum BL. Loss of the medial malleolus in a bimalleolar fracture. A case report. J Bone Joint Surg Am 1983 Oct;65(8):1184-1185.
  7. Hernigou P, Goutallier D. Absence of the medial malleolus. A case report with a 20-year follow-up study. Clin Orthop Relat Res 1991 Jun;267:141-142.
  8. Michelson JD, Waldman B. An axially loaded model of the ankle after pronation external rotation injury. Clin Orthop Relat Res 1996Jul;328:285-293.
  9. Solari J, Benjamin J, Wilson J, Lee R, Pitt M. Ankle mortise stability in Weber C fractures: indications for syndesmotic fixation. J Orthop Trauma 1991 Feb;5(2):190-195.
  10. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 1976 Apr;58(3):356-357.
  11. Takakura Y, Tanaka Y, Kumai T, Tamai S. Low tibial osteotomy for osteoarthritis of the ankle. Results of a new operation in 18 patients. J Bone Joint Surg Br 1995 Jan;77(1):50-54.
  12. Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma 1998 Jan;12(1):1-7.
  13. Yokoyama K, Itoman M, Uchino M, Fukushima K, Nitta H, Kojima Y. Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: a multivariate analysis of factors affecting deep infection and fracture healing. Indian J Orthop 2008 Oct;42(4):410-419.
  14. Ahmad J, Pour AE, Raikin SM. The modified use of a proximal humeral locking plate for tibiotalocalcaneal arthrodesis. Foot Ankle Int 2007 Sep;28(9):977-983.
  15. Boer R, Mader K, Pennig D, Verheyen CC. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail. Clin Orthop Relat Res 2007 Oct;463:151-156.
  16. Gavaskar AS, Chowdary N. Tibiotalocalcaneal arthrodesis using a supracondylar femoral nail for advanced tuberculous arthritis of the ankle. J Orthop Surg (Hong Kong) 2009 Dec;17(3):321-324.
  17. Niinimaki TT, Klemola TM, Leppilahti JI. Tibiotalocalcaneal arthrodesis with a compressive retrograde intramedullary nail: a report of 34 consecutive patients. Foot Ankle Int 2007 Apr;28(4):431-434.
  18. Pelton K, Hofer JK, Thordarson DB. Tibiotalocalcaneal arthrodesis using a dynamically locked retrograde intramedullary nail. Foot Ankle Int 2006 Oct;27(10):759-763.
  19. Brown TD, Johnston RC, Saltzman CL, Marsh JL, Buckwalter JA. Posttraumatic osteoarthritis: a first estimate of incidence, prevalence, and burden of disease. J Orthop Trauma 2006 Nov-Dec;20(10):739-744.
  20. Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA, Amendola A. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J 2005;25:44-46.
  21. Wyss C, Zollinger H. The causes of subsequent arthrodesis of the ankle joint. Acta Orthop Belg 1991;57(Suppl 1):22-27.
  22. Horisberger M, Valderrabano V, Hintermann B. Posttraumatic ankle osteoarthritis after ankle-related fractures. J Orthop Trauma 2009 Jan;23(1):60-67.
  23. Clarke HJ, Michelson JD, Cox QG, Jinnah RH. Tibio-talar stability in bimalleolar ankle fractures: a dynamic in vitro contact area study. Foot Ankle 1991 Feb;11(4):222-227.
  24. Michelsen JD, Ahn UM, Helgemo SL. Motion of the ankle in a simulated supination-external rotation fracture model. J Bone Joint Surg Am 1996 Jul;78(7):1024-1031.
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