Surgical Fixation of Lateral Malleolus Fractures with the Steel Cross Surgical Technique
Authors: Ricci Gianni , Stenslie Noah , Jardaly Achraf , Floyd John CP. , Harris Robert M. 
Published: November 2022

Category: Trauma; Ankle Introduction/Purpose: Malleolar fractures are a common orthopedic injury representing 9% of all fractures with an increasing incidence. For fractures requiring surgical management, internal fixation with a locking plate is commonly used. In an effort to deliver more cost-effective care, we utilize a technique termed Steel Cross (Figure 1) for fixation of the lateral malleolus. This technique incorporates a 1/3 tubular nonlocking plate with 3.5mm/2.7mm screws angled in the distal fibula to interlock the threads for fixation. This can be used in lieu of locking distal fibular plates and offers a 24.4% cost reduction. This pilot study was performed to compare the safety and efficacy of the Steel Cross versus standard locking plates for lateral malleolar fractures. Methods: This was a retrospective cohort study of patients who underwent open reduction and internal fixation for isolated lateral malleolar fractures. Consecutive patients treated with the Steel Cross were identified, and a control group of patients treated with a locking distal fibular plate was identified in a 1:1 ratio. Operative Technique: Standard direct lateral approach is used. Two 1.5mm cortical screws are placed lag by technique anterior to posterior perpendicular to the fracture. 1/3 tubular plate is contoured to distal fibula. A 3.5mm cortical screw is placed in 2nd-most distal hole unicortically. Three additional bicortical 3.5mm cortical screws are placed in the fibular shaft. Drill bit is used in the most distal hole angled obliquely proximal and posterior to the screw in the 2nd-most distal hole. 2.7mm cortical screw is then placed in that position interlocking the threads with the 3.5mm screw in the 2nd-most distal hole (Figure). Results: The study included 48 patients divided equally between Steel Cross patients (n=24) and locking plate patients (n=24). The majority were female (n=34, 70.8%), with an average age of 41.5 years (range:18- 81 years) and body mass index BMI of 31.9 kg/m2 (18.1-69.2 kg/m2). Both groups were similar in the age, sex, smoking, and diabetes distribution. All patients achieved union, and none experienced instrumentation break or fixation failure. Nine total complications were encountered, the most common being symptomatic instrumentation (n=6). Patients treated with the steal cross had three complications (12.5%): 2 symptomatic instrumentation and 1 surgical site infection. The other group had 6 complications (25%): 4 symptomatic instrumentations, 1 surgical site infection, and 1 wound dehiscence. The complication rate was not significantly different between groups. Conclusion: Open reduction and internal fixation is a safe and effective treatment for lateral malleolus fractures. The Steel Cross technique represents a viable alternative to locking plates in providing stable fixation. This technique achieved excellent union rates (100%) with a complication profile similar to that of locking plates while reducing implant cost by 24.4%.