Operative versus Non-Operative Management of The Medial Malleolus in Bimalleolar and Trimalleolar Fractures – A Systematic Review

Purpose Ankle fractures are the fifth most common fracture worldwide. Some reviews have shown that non-operative management of isolated medial malleolar fractures has satisfactory outcomes, and more recent studies have suggested the same may apply in bimalleolar and trimalleolar fractures (BTMF). Importantly, non-operative management has the added benefits of avoiding complications including wound infection, and protruding metalwork. This systematic review aims to compare operative and non-operative management of medial malleolar fractures in the context of BTMF. Methods A search syntax of MeSH terms was used to search ScienceDirect, Scopus, Cochrane Library, and PubMed databases. The methodological quality of the included studies was assessed according to the MINORS criteria. Data extracted included patient demographics, operative techniques, functional outcome scores (EQ-5D, OMAS, MOXFQ, VAS, AOFAS return to work/sports) and complication rates Results A total of four studies were included: one randomised-controlled and three prospective study. Two of these directly compared operative and non-operative approaches, while the remaining two reported solely an operative cohort. Of 373 total fractures, 274 were managed operatively and 99 non-operatively. There was no significant difference across all functional scores between operative and non-operative approaches to medial malleolar fractures in the comparative studies. However, there was an association for higher rates of mal/non-union in the non-operative groups (10.5% vs 5.0%). Conclusion Although there is existing belief that operative approach to BTMF would lead to better outcomes, there is currently no evidence that shows operative is superior to non-operative management. Orthopaedic surgeons should consider the morbidity of post-operative complications when deciding the treatment for medial malleolar fractures in BTMF, particularly in the elderly. Further studies need to be performed on this topic before a definitive conclusion can be made.