Medial malleolar fractures, forming part of the ankle joint injuries, are prevalent due to the pivotal role of the ankle in weight-bearing and locomotion. These fractures, if inadequately managed, may lead to post-traumatic arthritis, chronic pain, and gait abnormalities. Given the biomechanical complexity and functional importance of the ankle joint, appropriate internal fixation strategies are vital for anatomical restoration and optimal functional recovery [1,2].

Traditionally, open reduction and internal fixation (ORIF) remain the cornerstone for treating displaced medial malleolus fractures. Among various techniques, tension band wiring (TBW) and screw fixation are the most commonly employed. TBW converts tensile forces into compressive forces, favoring stable fixation especially in small or osteoporotic bone fragments [3,4]. Conversely, screw fixation, particularly with cannulated cancellous screws (CCS), is widely used due to ease of application and effective compression [5,6].

Several studies have attempted to compare the biomechanical properties, union rates, complications, and functional outcomes of these techniques [7–10]. However, consensus on superiority remains inconclusive. This study aims to compare these two methods based on functional outcomes using the Baird and Jackson scoring system.

This prospective study was conducted on 30 patients with either isolated medial malleolar fractures or fresh bimalleolar fractures.

Period of study: 2023 June to 2025 March

Place of work: Department of Orthopaedic, Government Medical College, Nalgonda

Inclusion Criteria:

• Patients aged between 18–70 years
• Closed or Grade 1 & 2 open fractures
• Fractures with articular step-off or comminution
• Medial malleolus fracture either isolated or part of bimalleolar injuries

Exclusion Criteria:

• Pathological fractures
• Age <18 or >70 years
• Cases treated conservatively

Procedure:  Patients were divided into two groups of 15 each. Group A underwent ORIF with tension band wiring, and Group B underwent screw fixation. The surgical techniques followed standard AO principles. Preoperative and postoperative assessments included radiographic evaluation and clinical examination. Follow-up continued for an average of 18 months.

Functional outcome was assessed using the Baird and Jackson scoring system, which considers pain, stability, ability to walk/run, return to work, and range of motion.

Thirty patients with isolated medial malleolar and fresh bimalleolar fractures, in which 15 patients were managed with tension band wiring to medial malleolus and another 15 patients were managed with screw fixation, were followed until fracture union occurred. Results were analysed both clinically and radio graphically. Almost all fractures united at the end of 10 weeks.

AGE DISTRIBUTION:

Majority of patients i.e. 12 (40%) were from 41- 50 years age group, followed by 8 (26.6%) patients in 21-30 age group. The youngest patient was 21 years old and oldest was 66 years of age. The mean age in our study was 42 years.

Table 1: Age Incidence

SEX DISTRIBUTION:

There was predominance of male over female patients in this study.

Table 2: sex incidence

OCCUPATION:

12 (40%) of patients who had fracture were daily laborers making up the majority followed by 10 (33.3%) of agricultural workers and 6 (20%) who were housewife.

Table 3: Occupation

MODE OF INJURY:

The major cause of fracture in our study was road traffic accidents in 15 (50%) and in 11 (36.6%) patients fracture was due to slipping and stumbling. The rest of the patients had fractures due to other causes.

Table 4: mode of injury

SIDE OF FRACTURES:

Right ankle was involved in 18 (60%) patients and in 12 (40%) patients left ankle was involved.

Table 5: Side of Fracture:

TYPE OF INJURY ACC. TO LAUGE HANSEN CLASSIFICATION:

In the present series 12 (40%) patients had supination and external rotation injuries which is the majority, followed by 9 (30%) patients with pronation external rotation injuries.

Table 6: Type of Injury as Determined by Lauge Hansen Classification

TYPE OF SURGERY:

In our study, 15 patients were managed with tension band wiring to medial malleolus while 15 patients were managed with screw fixation.

Table 7. Type of surgery done

PERIOD OF POSTOP IMMOBILIZATION:

Routine immobilization is done for a period of 5-6 weeks in below knee POP after fracture fixation by both tension band wiring and screw fixation.

Table 8. Period of immobilization postoperatively

ME TAKEN FOR FRACTURE UNION:

In this study most of the tension band wiring fixation cases united within 15 weeks i.e., out of 15 cases, only 2 cases took more than 15 weeks for union and no non-unions were reported. Out of 15 screw fixation cases 14 cases united by 10-15 weeks and 1 case took more than 15 weeks. No non-unions were reported

Table 9. Time taken for fracture union

SEVERITY OF PAIN:

In tension band wiring fixation, only 1 patient had moderate pain and 3 patients had mild pain after 6 months. Rest of them has no pain. No cases reported with severe pain. And in screw fixation, 2 patients had moderate pain and 3 had mild pain after 6 months. This is attributed to postoperative stiffness of ankle joint.

Table 10. Severity of the pain:

ASSESSMENT OF FUNCTIONAL OUTCOME:

Stability of ankle: All the patients had no clinical instability. Ability to walk: Majority 14 (93.3%) patients managed with tension band wiring could walk desired distances without limp or pain and one patient (6.66%) was able to walk desired distance with slight pain. In patients treated with screw fixation, 13 (86.6%) patients were able to walk desired distances without any difficulty while 2 (13.33%) patients were able to walk desired distance with slight pain.

Ability to run: Of the 15 patients managed by tension band wiring, 4 (%) patients were able to run deserved distances without pain, 10(%) patients were able to run desired distances with slight pain and 1(%) patients had moderate restriction in ability to run with mild pain. Of the 15 patients treated with screw fixation, 4 patients were able to walk desired distances without pain, 9 patients were able to run desired distances with slight pain and 2 (%) patients had moderate restriction in ability to run with mild pain.

Ability to work: In our series of patients managed with tension band wiring, 14 (93.3%) patients were able to perform usual occupation without restriction and the rest 1 (6.66%) patients were able perform usual occupation with restriction in some strenuous activities. In patients managed with screw fixation, 12 (80%) patients were able to perform usual occupation without restriction and the rest 3 (20%) patients were able perform usual occupation with restriction in some strenuous activities

Motion of ankle: In this series of patients managed with tension band wiring, 12 (80%) patients had range of motion of the ankle within 10° of uninjured ankle and 2 (13.3%) patients were having motion within 15° of uninjured ankle. The rest 1 (6.66%) patients had motion with in 20° of uninjured ankle.

In this series of patients managed with screw fixation, 10 (66.6%) patients had range of motion of the ankle within 10° of uninjured ankle and 3 (20%) patients were having motion within 15° of uninjured ankle. The rest 2 (13.3%) patients had motion with in 20° of uninjured ankle

Table 11: Final Score According to Subjective Objective and Radiological criteria

COMPOSITE SCORE:

In the present study of 15 patients with ankle fractures treated by open reduction and internal fixation by tension band                       wiring, Excellent results were achieved in 10 (66.6%) patients, good in 4 (26.6%), and Poor in 1 (6.66%) patient.

Of the 15 patients managed with open reduction and internal fixation, Excellent results were achieved in 8 (53.3%) patients, Good in 4 (26.6%), Fair in 2 (13.33%) and Poor in 1 (6.66%) patient.

The patient with poor result had mild pain with activities of daily living, diminution in the abilities to run and to do work, reduced motion of ankle and narrowing of joint space.

Table 12: Composite Score

Ho - functional outcome in both tension band wiring and screw fixation is equal. H1 - functional outcome with tension band wiring is superior to screw fixation in medial malleolar fracture management.

The level of confidence took was 95%. So the α value is 0.05. The t-value is 1.98 and the P value 0.048.

Both indicating to reject H0. And there is significant deference in the functional outcome for tension band wiring and screw fixation.

COMPLICATIONS:

Of all the 15 patients managed with tension band wiring, 3 patients had superficial skin infection which subsided with the usage of antibiotics, 1 patient developed mild reactive changes at joint margins. Of the series of patients managed with screw fixation, 2 patients had superficial skin infection which got subsided with the usage of oral antibiotics and one patient developed sinus with discharge after surgery which did not subside with antibiotics while one patient developed measurable joint space narrowing and arthritic changes on followup xrays.

Table13.Complications:

Ankle fractures are intra-articular injuries of a weight-bearing joint, requiring precise anatomical reduction and stable internal fixation to minimize residual disability, chronic pain, and post-traumatic arthritis [11,12]. The AO method of open reduction and internal fixation has consistently shown excellent outcomes in such fractures [12,13]. In the present study, 30 cases of isolated medial malleolar and bimalleolar fractures were treated—15 with tension band wiring (TBW) and 15 with cancellous screw (CCS) fixation—and followed for 18 months to evaluate functional outcomes using the Baird and Jackson scoring system [14].

The mean age of patients was 42 years, with no significant age difference between the groups, similar to findings by Baird and Jackson [14], Georgiadis et al. [15], and Lee et al. [16]. Males constituted 60% of cases, which corresponds with previous observations [7]. Road traffic accidents were the leading cause of injury, as also seen in other studies [16].

Supination-external rotation (SER) was the most common fracture pattern (40%), consistent with prior literature [14,18]. The right side was more frequently affected (60%), which aligns with results by Beris et al. [12]. The average union time was 12 weeks in both groups, comparable to findings by Gaurav et al. [19] and Ayyoub et al. [20]. TBW showed a slightly higher rate of delayed union but no non-unions, echoing the outcomes of Al-Lamy et al. [21] and Nurul et al. [22].

Functional outcomes were superior with TBW, with 93.3% achieving good to excellent results versus 79.9% in the CCS group, a statistically significant difference (p = 0.04), which agrees with the findings of Ko et al. [23] and Mohammed et al. [20]. TBW also showed better ankle range of motion and return to work scores (p < 0.05). These differences may be explained by the biomechanical advantage of TBW, which provides greater resistance to pronation forces and converts tensile into compressive forces at the fracture site [18].

Complication rates were comparable. Superficial infections were seen in both groups and resolved with antibiotics. One case of deep infection occurred in the screw group. There were no non-unions in either group, affirming the robustness of both fixation methods when properly applied [21,22].

Factors affecting outcomes included anatomical reduction, which proved to be the most crucial determinant, while fracture type (isolated vs. bimalleolar) had no significant influence [24]. POP slab immobilization for 6 weeks did not compromise final joint mobility, supporting AO principles and prior reports [12].

In conclusion, both TBW and CCS fixation are effective methods for managing medial malleolus fractures. However, TBW provides marginally better functional outcomes, particularly in terms of joint mobility and return to activity.

Ethical Clearance: Ethical Clearance Certificate was obtained from the Institutional Ethics Committee (IEC) prior to commencement of study

Conflict of Interest: Nil - No conflict of interest

Source of funding: Self

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