Medial malleolus: Operative Or Non-operative (MOON) trial protocol - a prospective randomised controlled trial of operative versus non-operative management of associated medial malleolus fractures in unstable fractures of the ankle

Abstract

Background: There are limited data reporting the outcome of patients with non-operatively managed medial malleolus fractures compared to those treated surgically in the presence of fibular stabilisation for unstable fractures of the ankle. Conservative management could result in fewer complications, reduced surgical time and lower cost. The purpose of this study is to determine if any difference exists in patient reported and surgical outcomes 1 year after surgery between operative and non-operative treatment of medial malleolar fractures in combination with stabilisation of the lateral malleolus.

Methods/design: This is a single-centre, prospective, randomised controlled trial that aims to randomise 154 participants with an unstable ankle fracture to 'non-fixation' (n = 77) or 'fixation' (n = 77) of an associated well-reduced medial malleolus fracture following fibular stabilisation. The study will include patients ≥ 16 years of age with a closed bimalleolar or trimalleolar ankle fracture who are able to consent, complete questionnaires in the English language, and complete follow-up over a 1-year period. Randomisation will occur intra-operatively when the medial malleolus fracture is deemed 'well-reduced', with 2 mm or less of fluoroscopic displacement. The technique for fixation of both the medial and lateral malleoli is at the discretion of the operating surgeon. Patient-reported, observer-rated, and radiographic assessments will be collected at baseline and then at the following post-operative assessment points: 2 weeks, 6 weeks and 1 year. Postal questionnaire outcome data will be collected at 3 and 6 months. The primary outcome measure will be the Olerud Molander Ankle Score (OMAS) at 1 year following surgery. Secondary outcome measures will include the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5D (EQ-5D), pain, treatment satisfaction, time to return to activity, operative tourniquet time, and complications.

Discussion: There is only one previous randomised trial comparing non-fixation with fixation of associated medial malleolus fractures but that was limited by the lack of baseline patient-reported outcome data and an inferior sample size. This current prospective trial aims to provide high-quality evidence regarding the requirement for medial malleolar fixation in unstable ankle fractures.

Trial registration: ClinicalTrials.gov, NCT03362229 . Registered retrospectively on 5 December 2017.

Keywords: Ankle fractures; Fracture fixation; Medial malleolus; Patient outcome; Randomised controlled trial; Trauma.

Conflict of interest statement

The authors declare they have no competing interests.

Figures

Fig. 1

Planned flow of participants. MCID minimal clinically important difference, PRO patient-reported outcome, SD standard deviation, XR x-ray

Fig. 2

Anteroposterior radiograph of a supination-external rotation stage IV fracture at the time of injury and following fibular stabilisation, demonstrating an anatomically reduced medial malleolus. This patient would be eligible for intra-operative randomisation

Fig. 3

Anteroposterior radiograph of a supination-external rotation stage IV fracture at the time of injury and following fibular stabilisation. The medial malleolus has not reduced to acceptable limits, likely incarcerated by soft tissue. This patient would not be eligible for intra-operative randomisation

Fig. 4

Schedule of enrolment, interventions, and assessments. *Data collected through postal questionnaire. EQ-5D EuroQol 5D, MOXFQ Manchester-Oxford Foot Questionnaire, OMAS Olerud Molander Ankle Score