Intraoperative Arthrography for the Evaluation of Closed Reduction and Percutaneous Fixation of Displaced MacFarland Fractures: An Alternative to Open Surgery

Background: MacFarland fracture is a joint fracture of the ankle in children involving the medial malleolus (Salter-Harris type III or IV). These fractures are acknowledged to have poor prognosis because of the risk of misalignment due to the development of an epiphysiodesis bridge. Current recommended treatment for a displacement of >= 2 mm is open reduction through an arthrotomy with screw fixation. This study aimed to evaluate functional and radiologic results of a less-invasive surgical technique consisting of closed reduction, arthrographic control of fracture reposition, and percutaneous screw fixation. Methods: Retrospective analysis of 12 cases of children with MacFarland fractures who underwent percutaneous screw fixation with intraoperative arthrography. Data collected for each child included age, sex, radiologic Salter-Harris classification of medial and lateral malleolus fractures, fracture gap before and after treatment, intraoperative and postoperative complications, and length of follow up. Results were evaluated according to the 3 outcome categories according to the classification by Gleizes and based on clinical and radiologic criteria. Results: There were 7 boys and 5 girls with an age range of 10 to 15 years (average, 12 y 6 mo). Average follow-up was 18 months (range: 9 to 57 mo). Medial malleolus fracture was Salter-Harris type III in 7 patients and type IV in 5. There were 9 Salter-Harris type I fractures and 1 type II at the level of the distal fibular physis. The mean preoperative gap was 2.8 mm (1.9 to 4 mm). Fracture fixation was performed with 2 screws in 9 patients and 1 screw in 3 patients. Mean surgical time was 58 minutes (45 to 75 min). The mean postoperative articular gap was 0 mm in 8 patients, inferior to 1 mm in 3 patients, and 2 mm in 1 patient. At the time of last follow-up, the outcome was considered good in all but 1 patient. Conclusions: Closed reduction combined with ankle arthrography followed by percutaneous osteosynthesis is an interesting and less invasive safe surgical alternative to classic open reduction and internal fixation of displaced MacFarland fractures.