The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: Abstract
Intravenous tranexamic acid (TXA) has been shown
to be effective in reducing blood loss and the need for transfusion
after joint replacement. Recently, there has been interest in applying
it topically before the closure of surgical wounds. This has the
advantages of ease of application, maximum concentration at the
site of bleeding, minimising its systemic absorption and, consequently,
concerns about possible side-effects. We conducted a systematic review and meta-analysis which included
14 randomised controlled trials (11 in knee replacement, two in
hip replacement and one in both) which investigated the effect of
topical TXA on blood loss and rates of transfusion. Topical TXA
significantly reduced the rate of blood transfusion (total knee
replacement: risk ratio (RR) 4.51; 95% confidence interval (CI):
3.02 to 6.72; p <
0.001 (nine trials, I2 = 0%); total
hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)).
The rate of thromboembolic events with topical TXA were similar
to those found with a placebo. Indirect comparison of placebo-controlled
trials of topical and intravenous TXA indicates that topical administration
is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of
reducing the need for blood transfusion after total knee and hip
replacement. Further research is required to find its optimum dose
for topical use. Cite this article:
