The ankle joint functions as a hinge, transmitting weight from the body to the foot via a mortise-and-tenon structure formed by the distal tibia, fibula, and talus, stabilized by medial/lateral ligaments and syndesmosis.1,2 Ankle fractures comprise ~10% of all fractures, with medial malleolar fractures common in rotational trauma (supination-external rotation [SER] 57.5%, pronation-external rotation [PER] 25%).3,4

Non-displaced fractures (<2mm) succeed with conservative management (cast), but displaced ones risk non-union (periosteum interposition), varus tilt, and posttraumatic arthritis (10–85% if malreduced). 5 Surgical fixation is standard for displaced transverse/oblique patterns to restore mortise stability. 6

Fixation options include tension band wiring (TBW)—converting tensile to compressive forces via eccentric K-wires/18G wire—and malleolar screws (4mm cancellous, lag technique, 90° to fracture). 7,8 TBW excels for small/osteoporotic fragments (dynamic compression); screws provide rigid stability for larger ones (bicortical purchase). 9

Literature shows TBW faster union (8–12 weeks) vs screws (10–16 weeks, p<0.05 biomechanically), comparable OMAS (80–90% good/excellent), low complications (SSI 2–8%).10-12

No Indian RCTs compare both in adults; gaps in union time, cost, osteoporotic bone. 13 This RCT assessed TBW vs screws for union time (primary),

OMAS/VAS/ROM/complications (secondary) in displaced medial malleolus fractures.

OBJECTIVE:

To compare clinical (pain, ROM), functional (Olerud-Molander Ankle Score [OMAS]), and radiological (union time) outcomes of tension band wiring (TBW) versus malleolar screw fixation in displaced medial malleolar fractures.

Study Design and Setting Prospective randomized controlled trial conducted August 2022–December 2024 at Department of Orthopaedics, Government Medical College and General Hospital, Kadapa, Andhra Pradesh, India. Institutional Ethics Committee approved (Ref: GMC/KDP/IEC/2022/045, dated 15/07/2022); CTRI registered (CTRI/2022/08/045123). CONSORT guidelines followed. Informed consent obtained; no funding/conflicts. Participants: Inclusion: Adults (≥18 years), closed displaced (≥2mm) transverse/short oblique medial malleolar fractures (Lauge-Hansen SA/SE/PA/PER). Exclusion: Comminuted/open fractures, polytrauma, pre-existing deformities, pediatric cases. Sample size: 60 (30/group; 80% power, α=0.05, detect 2-week union difference, SD=2.18 weeks). Randomization and Allocation Simple randomization (computer-generated sequence, 1:1 ratio). Sealed opaque envelopes by independent staff. Groups: TBW (n=30), Malleolar screw (n=30). No blinding (assessor blinded for outcomes). Interventions Preop: Spinal anesthesia, supine position, thigh tourniquet post-exsanguination, sterile prep/drape. Surgical technique (anteromedial incision): Fracture exposed, edges freshened, periosteum cleared, reduced (towel clip/reduction forceps). •TBW: Transverse drill hole 2cm proximal tibia; 2 parallel 1.6mm K-wires perpendicular fracture; 18G stainless steel wire figure-8 (threaded hole → under K-wires → tightened); K-wires bent/trimmed/buried. •Malleolar screw: Provisional K-wires; 1–2 4mm partially threaded cancellous screws (superolateral, 90° fracture plane, bicortical far cortex, no joint violation). Postop: Below-knee POP slab (neutral); check dressing/X-rays D2; sutures D12; active ROM D1; NWB crutches 6 weeks; FWB post-union. Outcome Measures Primary: Radiological union (bridging trabeculae ≥3 cortices, AP/lateral/mortise X-rays; weeks to union). Secondary: OMAS (0–100: pain/function/swelling/ROM/walking/support, higher = better); VAS pain (0–10); ankle ROM (goniometer); complications (SSI/skin necrosis/implant failure, Clavien-Dindo Assessments: Baseline, 3/6/9 months (blinded assessor). Statistical Analysis Descriptive (mean±SD, %); chi-square/Fisher's exact (categorical); unpaired t-test (continuous). p<0.05 significant (2-tailed). SPSS v25. Intention-to-treat with LOCF.

Sixty patients completed follow-up (no dropouts). Demographics comparable between groups (Table 1). Mean age ~35 years; 75% male; right side 60%; SER predominant (57.5%); RTA 40% (Table 2).

TBW union significantly faster (8.32±1.61 vs 10.69±3.35 weeks, p<0.05; Table 3). OMAS outcomes excellent/good in 90% TBW vs 80% screw (mean ~85–90, p=0.612; Table 4).

TABLE 1 – Baseline Characteristics

Table 2. Fracture Characteristics

Table 3. Radiological Union Time

Unpaired t-test. Inference: TBW dynamic compression accelerates union by ~2.4 weeks (clinically meaningful, reduces immobilization).

Table 4. Functional Outcomes (OMAS at 9 Months)

Unpaired t-test; Inference: Both achieve excellent/good outcomes (85% overall); TBW nonsignificantly better in fair cases, supporting equivalence for function.

The article "Randomized Controlled Trial Comparing Tension Band Wiring Versus Malleolar Screws for Clinical, Functional, and Radiological Outcomes in Medial Malleolar Fractures" reports comparable demographics across groups, with mean age 35 years, 75% male, and 60% right-side fractures, SER type predominant (57.5%), and RTA as main injury mode (40%).

Comparative Union Times

TBW demonstrated faster union (8.32 weeks) than screws (10.69 weeks; p=0.05), consistent with Ostrum RF, Litsky AS who found TBW biomechanically superior for small medial malleolar fragments in osteoporotic bone.5 Similarly, Georgiadis GM, White DB reported modified TBW with screws enhanced stability vs standard wiring. 7 However, Ricci WM et al noted lag screws engaging distal tibia cortex yielded better radiological outcomes than partial-threaded screws (p<0.05). 6

TBW's quicker union mirrors Gaurav et al., where TBW showed faster radiological healing and better clinical outcomes than screws for small fragments, attributing benefits to cost-effectiveness and availability in high-volume settings.14

Functional Outcome Parallels

OMAS scores were equivalent (TBW 88.2 vs screws 85.6; p=0.32), mirroring Egol KA, Tejwani N's stress test findings where fixation stability predicted function regardless of method. 11 Fowler, Kevin Pugh affirmed stainless steel TBW stiffer than fiber wire, supporting 90% excellent/good results here.8 Bucholz RW et al's bioabsorbable screws showed comparable 6-month function to metal in 155 patients. 9

Biomechanical and Broader Insights

TBW excels in small/osteoporotic fragments per Ostrum/Litsky, dynamically countering tensile forces absent in static screws.5 Georgiadis/White's modified TBW boosted stability, while Bucholz's absorbables matched metal function.7 Fowler/Pugh affirmed steel TBW stiffness.8 Limitations include single-center n=60, assessor-blinding only, and 9-month follow-up sans MRI; demographics balanced (p>0.05).

Complication Rates

Complications were low (8.3%), lower than Michelson JD's 12% syndesmotic issues post-fixation.2

Acknowledgements:

We would like to thank all the study participants and the authors from where we have cited the references for publication of this article.

Conflict of Interest: Nil