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Zhang D, Litvak A, Lin N, Pirkle S, Strelzow J, Hynes K. Current Trends in the Surgical Treatment of Fibular Fractures: A National Database Study of Intramedullary vs. Plate Fixation Practice Patterns, Complications, and Cost. Adv Orthop 2024; 2024:7506557. [PMID: 39036541 PMCID: PMC11260212 DOI: 10.1155/2024/7506557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/14/2024] [Accepted: 06/24/2024] [Indexed: 07/23/2024] Open
Abstract
Existing primary evidence comparing fibular intramedullary fixation (IMF) with traditional plate fixation (PF) for the treatment of distal fibular fractures remains limited by modest sample sizes. Using a large national database, this study aims to compare use rates, fracture patterns, patient characteristics, time to surgery, complication rates, and cost between fibular IMF and PF within the United States. Adults treated with fibular IMF or PF between October 2015 and October 2021 were identified within the PearlDiver Database. The ratio of IMF-treated to PF-treated patients was tracked temporally to compare use rates. Fracture patterns were determined using fracture diagnoses within one-month preceding surgery. Further comparisons of IMF- and PF-treated groups only included patients with at least 12 months of follow-up, and patients with upper tibia or tibia shaft fractures were excluded. An analysis of cohorts matched at a 1 : 4 (IMF: PF) ratio to control for risk factors was performed to compare time to surgery, complication rates (infection, nonunion, malunion, revision, hardware removal, pulmonary embolism, and deep vein thrombosis), and cost. 39329 patients (2294 IMF and 37035 PF) were identified. IMF use trended upwards relative to PF use over time. Tibia and fibula shaft fractures were the most common injuries in IMF patients versus bimalleolar and trimalleolar fractures in PF patients. A higher proportion of IMF patients had open fractures. IMF patients were younger, with higher mean ECI, fewer female patients, and higher rates of CKD. Percutaneous approaches were more common among IMF patients. There were no significant differences in time to surgery or complication rates. IMF was less costly. The popularity of IMF trended upwards across the study period. IMF was used more commonly in injuries involving higher energy trauma and soft tissue disruption. Overall, IMF patients were younger with more comorbidities. When used in similar populations, IMF appears to be a cost-effective alternative to PF.
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Affiliation(s)
- Douglas Zhang
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Audrey Litvak
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Nicholas Lin
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
| | - Sean Pirkle
- Department of Orthopaedics and Sports MedicineUniversity of Washington, Seattle, WA 98195, USA
| | - Jason Strelzow
- Department of Orthopaedic Surgery and Rehabilitation MedicineUniversity of Chicago Medicine, Chicago, IL 60637, USA
| | - Kelly Hynes
- Department of Orthopaedic Surgery and Rehabilitation MedicineUniversity of Chicago Medicine, Chicago, IL 60637, USA
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Samuel Z, Hong IS, Deliso M, Passannante L, Zapf CG, Tang A, Jankowski JM, Liporace FA, Yoon RS. Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202407000-00009. [PMID: 38996216 PMCID: PMC11239172 DOI: 10.5435/jaaosglobal-d-24-00119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION The purpose of this systematic review and meta-analysis was to provide an update of the recent literature comparing clinical outcomes of surgically treated fibular fractures using intramedullary nailing (IMN) with open reduction and internal plate fixation (ORIF). METHODS A literature search reporting clinical outcomes after IMN or ORIF of the distal fibula was conducted on PubMed. Inclusion criteria consisted of original studies; studies focusing on clinical outcomes after IMN or IMN and ORIF published before May 11, 2022; studies with at least 5 patients; and studies reporting union rates, complication rates, and patient-reported outcomes such as American Orthopaedic Foot and Ankle Society (AOFAS) and Olerud-Molander scores. RESULTS Of 2,394 studies identified, a total of 29 studies (4 LOE-I, 2 LOE-II, 6 LOE-III, 17 LOE-IV) were included consisting of 1,850 IMN patients and 514 plate patients. The pooled mean age of IMN patients was 58 years (95% confidence interval [CI], 54 to 62, I2 = 42%) versus 57 years (95% CI, 53 to 62, I2 = 49%) in ORIF. Union rates for IMN patients revealed a 99% union rate (95% CI, 0.98 to 1.00, I2 = 20%) versus 97% union rate for ORIF patients (95% CI, 0.94 to 0.99, I2 = 0%). Studies that compared IMN with ORIF revealed no difference in union rates (risk ratio [RR] = 0.99, 95% CI, 0.96 to 1.02, I2 = 0%). IMN patients showed a 15% complication rate (95% CI, 0.09 to 0.23, I2 = 89%), whereas plate patients had a complication rate of 30% (95% CI, 0.18 to 0.46, I2 = 63%). When comparing studies with both treatments, IMN patients had a significantly lower risk of complications (RR = 0.49, 95% CI, 0.29 to 0.82, I2 = 50%). The IMN group trended toward a higher mean AOFAS and Olerud-Molander score than the plate group by 4.53 (95% CI, -14.58 to 23.65, I2 = 85%) and 3.54 (95% CI, -2.32 to 9.41, I2 = 76%) points, respectively. CONCLUSION Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation. While IMN patients had higher AOFAS and Olerud-Molander scores, these differences were not statistically significant. Notably, subgroup analyses indicated that rates of symptomatic implant and removal of implant were comparable between IMN and ORIF, which may indicate that wound-related complications were reduced in the minimally invasive IMN technique. While the high cost of IMN implants remains a barrier to their widespread adoption, the long-term benefits of reducing complications, specifically associated with wound complications in high-risk populations, may greatly improve quality of care for patients with distal fibula fractures. Additional research and cost-effectiveness analyses are warranted to fully assess the long-term benefits and economic feasibility of using IMN fixation for distal fibula fractures. LEVEL OF EVIDENCE Therapeutic Level IV.
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Affiliation(s)
- Zachariah Samuel
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Ian S. Hong
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Marisa Deliso
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Luke Passannante
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Christian G. Zapf
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Alex Tang
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Jaclyn M. Jankowski
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Frank A. Liporace
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
| | - Richard S. Yoon
- From the Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center, RWJBarnabas Health Livingston/Jersey City, NJ
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Fibula Nail versus Locking Plate Fixation-A Biomechanical Study. J Clin Med 2023; 12:jcm12020698. [PMID: 36675627 PMCID: PMC9862725 DOI: 10.3390/jcm12020698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/10/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
In the treatment of ankle fractures, complications such as wound healing problems following open reduction and internal fixation are a major problem. An innovative alternative to this procedure offers a more minimally invasive nail stabilization. The purpose of this biomechanical study was to clarify whether this method was biomechanically comparable to the established method. First, the stability (range of motion, diastasis) and rotational stiffness of the native upper ankle were evaluated in eight pairs of native geriatric specimens. Subsequently, an unstable ankle fracture was created and fixed with a locking plate or a nail in a pairwise manner. The ankles showed significantly less stability and rotational stiffness properties after nail and plate fixations than the corresponding native ankles (p < 0.001 for all parameters). When comparing the two methods, both showed no differences in their range of motion (p = 0.694) and diastasis (p = 0.166). The nail also presented significantly greater rotational stiffness compared to the plate (p = 0.001). However, both fixations remained behind the native stability and rotational stiffness. Due to the comparable biomechanical properties of the nail and plate fixations, an early weight-bearing following nail fixation should be assessed on a case-by-case basis considering the severity of fractures.
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Barlow C, Duggleby L, Barton T. Early weight bearing in elderly patients with ankle fractures reduces care needs and maintains independence. Foot Ankle Surg 2023; 29:63-66. [PMID: 36175269 DOI: 10.1016/j.fas.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/02/2022] [Accepted: 09/19/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ankle fractures in the elderly are increasingly prevalent and are associated with significant morbidity and loss of independence. METHOD Patients over the age of 70 suffering ankle fracture were identified using ICD-9-CM patient coding. Fracture stability was assessed using patient records and radiographic evidence. Management strategy, length of inpatient stay, time non-weight bearing, pre-admission residence, discharge destination and discharge care needs were studied. RESULTS 169 patients with a mean age 80.3 years were studied. Management strategy was shown to have a significant effect on a patient's care requirements (p = 0.012) and ability to return to their primary residence (p = 0.014). Management via an intramedullary rod was associated with the lowest rates of increased care needs (29.7%) and the highest rate of returning home on discharge (88.9%). CONCLUSIONS Early weight bearing had a significant effect on a patient's ability to maintain independent living and were more likely to return to their own home.
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Affiliation(s)
- Ciaran Barlow
- Department of Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, UK.
| | - Luke Duggleby
- Department of Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, UK.
| | - Tristan Barton
- Department of Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, UK.
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Guo W, Wu F, Chen W, Tian K, Zhuang R, Pan Y. Can Locked Fibula Nail Replace Plate Fixation for Treatment of Acute Ankle Fracture? A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2022; 62:178-185. [PMID: 36333182 DOI: 10.1053/j.jfas.2022.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/13/2022] [Accepted: 10/01/2022] [Indexed: 11/07/2022]
Abstract
The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with several complications, such as soft tissue irritation, wound infection, and nerve injury. Previous studies have shown that closed reduction and internal fixation with locked intramedullary nails (LIMNs) yields satisfactory efficacy in the treatment of ankle fractures and is associated with low complication rates. Therefore, a systematic review and meta-analysis of randomized controlled trials is imperative to provide evidence on whether or not LIMN fixation is comparable to or superior than traditional ORIF. We conducted a comprehensive literature search in the PubMed, Cochrane Library and EMBASE databases. A total of 4 randomized controlled trials involving 359 participants who suffered ankle fractures were included in this systematic review and meta-analysis. The results showed that the LIMN fixation group was statistically significant in terms of functional outcomes at the 3-month follow-up and wound-related complications. There was no statistical advantage for patients in the LIMN fixation group in terms of nonwound-related complications, total complications, or mid-term follow-up functional outcomes. There was no statistical difference between the LIMN and ORIF groups regarding operation time and quality of reduction. We believe LIMN fixation is a viable option for the treatment of unstable ankle fractures in both young and elderly individuals.
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Affiliation(s)
- Wenxuan Guo
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Fan Wu
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Wenhuan Chen
- Third Clinical Medical School, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Kun Tian
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Rujie Zhuang
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yu Pan
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University, The First Clinical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
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Bastías GF, Bravo F, Astudillo C, Giannini E, Contreras M, Melo R, Muñoz G, Pellegrini MJ, Cuchacovich N. Restoration of Anatomic Parameters and Syndesmotic Reduction After Intramedullary Nailing of Distal Fibular Fractures. FOOT & ANKLE ORTHOPAEDICS 2022; 7:24730114221141388. [PMCID: PMC9742579 DOI: 10.1177/24730114221141388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Intramedullary nailing of the fibula (FN) is a method of fixation that has proven to be useful for treating distal fibular fractures (DFs). FN minimizes soft tissue complications and provides similar stability to plating, with fewer hardware-related symptoms. Nevertheless, FN has been associated with syndesmotic malreduction and the incapacity of restoring length and rotation of the fibula. We aimed to evaluate the fibular position and syndesmotic reduction after fixation with FN compared with the uninjured ankle in the immediate postoperative period. Methods: Prospective cohort study. Patients with DF fractures treated with IN between January 2017 and January 2020 were included. Immediate postoperative bilateral ankle CT was obtained in all cases. Fibular rotation, length, and translation as well as syndesmotic diastasis were measured on both ankles and compared by 3 independent observers. Results: Twenty-eight patients were included (16 women). The mean age was 46 years (range 16-91). Fracture type distribution according to AO/ASIF classification included 19 patients with 44.B (67.9%), 8 patients with 44.C (28.6%), and 1 patient with a 44.A fracture (3.6%). No significant differences were identified considering fibular rotation (P = .661), syndesmotic diastasis (P = .147), and fibular length (P = .115) between the injured and uninjured ankle. Fibular translation had statistical differences (P = .01) compared with the uninjured ankle. The intraclass correlation coefficient showed an excellent concordance between observers except for fibular translation on the injured ankle. Conclusion: In this cohort, fixation of DF fractures with FN allows restoration of anatomical parameters of the ankle in terms of fibular rotation, length, and syndesmotic diastasis. However, fibular translation had significant differences compared with the uninjured ankle based on bilateral CT scan evaluation. Level of Evidence: Level II, prospective cohort study.
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Affiliation(s)
- Gonzalo F. Bastías
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clínica Las Condes—Hospital del Trabajador, Universidad de Chile, Las Condes, Santiago, Chile
| | - Francisco Bravo
- Department of Orthopedic Surgery, Foot and Ankle Unit, Complejo Hospitalario San José—Mutual de Seguridad, Santiago, Chile
| | - Claudia Astudillo
- Department of Radiology, Clinica Las Condes, Las Condes, Santiago, Chile
| | - Esteban Giannini
- Department of Radiology, Hospital del Trabajador-Clinica MEDS, Santiago, Chile
| | - Martin Contreras
- Department of Orthopedic Surgery, Hospital del Trabajador, Santiago, Chile
| | - Rodrigo Melo
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes—Hospital Militar de Santiago, Santiago, Chile
| | - Gerardo Muñoz
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes, Las Condes, Santiago, Chile
| | - Manuel J. Pellegrini
- Department of Orthopedic Surgery, Foot and Ankle Service, Clinica Universidad de los Andes—Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Natalio Cuchacovich
- Department of Orthopedic Surgery, Foot and Ankle Unit, Clínica Las Condes—Hospital del Trabajador, Universidad de Chile, Las Condes, Santiago, Chile,Natalio Cuchacovich, MD, Department of Orthopedic Surgery, Foot and Ankle Unit, Clinica Las Condes—Hospital del Trabajador, Estoril 450, Las Condes, Santiago, 7591047, Chile.
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A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary "Photodynamic Bone Stabilisation". J Clin Med 2022; 11:jcm11237178. [PMID: 36498750 PMCID: PMC9736249 DOI: 10.3390/jcm11237178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.
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Raj V, Barik S, Richa. Distal Fibula Fractures-Intramedullary Fixation Versus Plating: A Systematic Review and Meta-analysis of Randomized Control Trials. Foot Ankle Spec 2022:19386400221118470. [PMID: 36004427 DOI: 10.1177/19386400221118470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of the present study is to compare the functional scores and complications of intramedullary fixation versus plate osteosynthesis of distal fibular fractures in adults. METHODS Study was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses format from MEDLINE, Embase, Ovid, and Cochrane databases. The included articles were assessed according to the risk of bias assessment tool by Cochrane collaboration. RESULTS A total of 5 randomized control trials were included for quantitative review. Random sequence generation and allocation concealment of the study subjects were the strengths of all the included studies. There was high heterogeneity among the included studies (I2 > 75%). There was no significant difference between the Olerud-Molander scores in both the groups but the trend favored the intramedullary nailing of distal fibula (mean difference of 3.42, 95% confidence interval [CI] of 8.90). Complications were significantly lesser in the intramedullary group across the studies (odds ratio 0.26, 95% CI of 0.81). CONCLUSION Intramedullary nailing of fibula with the use of modern locking fibular nails is an alternative to fibular plating for unstable distal fibular fractures in properly selected cases. There remains the need for standardizing the method of operative treatment of distal fibular fractures which can be done by a well-planned large-scale prospective study design. LEVEL OF EVIDENCE Level 1.
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Affiliation(s)
- Vikash Raj
- Department of Orthopedics (VR, SB) and Department of Community and Family Medicine (R), All India Institute of Medical Sciences, Deoghar, JH, India
| | - Sitanshu Barik
- Department of Orthopedics (VR, SB) and Department of Community and Family Medicine (R), All India Institute of Medical Sciences, Deoghar, JH, India
| | - Richa
- Department of Orthopedics (VR, SB) and Department of Community and Family Medicine (R), All India Institute of Medical Sciences, Deoghar, JH, India
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Odeh A, Archer J, Budair B, Marsh A, Fenton P. Management of Open Ankle Fractures in Elderly Patients With a Fibula Nail is a Safe and Reliable Technique. Foot Ankle Spec 2022:19386400221099660. [PMID: 35770327 DOI: 10.1177/19386400221099660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ankle fractures are becoming more common in the elderly and their management is frequently challenging. There is increasing evidence of good outcomes following fibula nail fixation in the management of ankle fractures. The use of a fibula nail in open fractures comes with potential advantages such as minimal soft tissue dissection, early rehabilitation, and decreased wound complications. We aimed to assess their use in the management of open ankle fractures in the elderly. METHODS A review of patients aged 60 years or older with an open ankle fracture treated with a fibular nail at a major trauma center was conducted. All patients were managed with joint Orthopaedic and Plastic Surgical input to determine their optimal management. Functional outcome scores, postoperative complications, and re-operation rates were determined. RESULTS Fifteen patients were identified with a mean age of 76 years. Patient-reported outcomes (Olerud and Molander Score) were calculated in 73% of patients. Our results demonstrated excellent outcome scores (>91) in 1 patient, good outcome scores (61-90) in 7 patients, and fair outcome scores (31-60) in 3 patients. There were no postoperative complications or re-operations within our study group. CONCLUSION This article is the largest series presenting the outcomes of fibula nails in the management of open ankle fractures in elderly patients. We conclude that it can be used as a treatment option to safely manage open ankle fractures in the elderly. It provides a stable fixation, early weight-bearing, low risk of postoperative complications while maintaining good patient-reported functional outcomes. LEVEL OF EVIDENCE Level 4.
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Dang Q, Leijdesdorff HA, Hoogendoorn JM, Emmink BL. Factors Affecting Hospital Length of Stay in Geriatric Patients With a Surgically Treated Fragility Ankle Fracture. J Foot Ankle Surg 2022; 61:490-496. [PMID: 34763998 DOI: 10.1053/j.jfas.2021.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 06/14/2021] [Accepted: 09/26/2021] [Indexed: 02/03/2023]
Abstract
Fragility ankle fractures in elderly have a rising incidence and hospitalization may be prolonged due to pre-existing comorbidities, compromised soft tissue and postoperative difficulties in the rehabilitation process. The aim of this retrospective cohort study was to investigate risk factors for longer total hospitalization duration in elderly patients with surgically treated fragility (Lauge Hansen supination external rotation type 4) fractures. We included all patients ≥ 70 years with a fragility fracture, who were treated surgically between 2011 and 2019 (n = 97) in a level 1 and 2 trauma center. Data on patient demographics, fracture characteristics, surgical treatment strategies and postoperative complications were retrieved from medical records. Multivariate regression analysis was performed to identify independent risk factors for longer hospitalization duration. The mean age of the included patients was 78.27 (± 6.56) years; 71 patients (73.20%) were female. Ten fractures (10.30%) were classified as open and 49 (50.50%) as a luxation type fracture. Fifty-nine patients (60.80%) were hospitalized after admission to the emergency department. External fixation was performed in 34 patients (35.10%) and served as bridge to definitive fixation in 29 patients (85.30%). The mean total hospital length of stay of all patients was 7.04 (± 6.58) days. Multivariate regression analysis demonstrated that the use of external fixation (p < .001) and the postoperative discharge destination (p < .001) were independently associated with a prolonged hospital stay. External fixation and discharge destination were independent risk factors for a prolonged hospital stay in elderly patients with a fragility fracture.
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Affiliation(s)
- Quan Dang
- Trauma Unit, Haaglanden Medical Centre, the Hague, the Netherlands
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Kho DH, Cho BK, Choi SM. Midterm Outcomes of Unstable Ankle Fractures in Young Patients Treated by Closed Reduction and Fixation With an Intramedullary Fibular Nail vs Open Reduction Internal Fixation Using a Lateral Locking Plate. Foot Ankle Int 2021; 42:1469-1481. [PMID: 34184908 DOI: 10.1177/10711007211017470] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We aimed to compare midterm radiological and clinical outcomes between closed reduction and internal fixation (CRIF) using the fibular intramedullary nail (IMN) and open reduction and internal fixation (ORIF) using the locking plate for the treatment of unstable ankle fractures in active young patients. METHODS In this retrospective cohort study, 204 patients treated with CRIF using the fibular IMN (94 patients) or ORIF using the locking plate (110 patients) were included after at least 3 years of follow-up. The mean patient age was 41.4 years. Radiographic evaluation included the quality of reduction assessed by plain radiography and 3-dimensional (3D)-reconstructed computed tomography as well as the development of posttraumatic osteoarthritis (PTOA) of the ankle assessed by weightbearing plain radiography. Clinical evaluation included the American Orthopaedic Foot & Ankle Society hindfoot score, Olerud and Molander Score, the Foot and Ankle Outcome Score, and visual analog scale pain score as well as complications. RESULTS At median follow-up greater than 4 years, we found no significant differences in measured clinical outcomes between the 2 groups. There were significantly fewer postoperative complications in the IMN group than in the ORIF group (9.5% vs 39%, P < .001). However, we did find a greater proportion of radiographically fair or poor reductions in the IMN group than in the ORIF group (P < .001). The poor reductions in the IMN group were primarily related to Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures (P < .001). PTOA was also more frequently observed in the IMN group than in the ORIF group (21.3% vs 9.1%, P = .024). CONCLUSION Given the current prevailing technologies for fracture fixation, this study suggests that surgeons should consider ORIF for unstable ankle fractures in active young patients with Weber type C, pronation-type injury, and comminuted fibular and trimalleolar fractures. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Duk-Hwan Kho
- Department of Orthopaedic Surgery, Konkuk University Chungju Hospital, Konkuk University School of Medicine, Chungju, Korea
| | - Byung-Ki Cho
- Department of Orthopaedic Surgery, School of Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Seung-Myung Choi
- Department of Orthopedic Surgery, Eulji University School of Medicine, Gyeonggi-do, Korea
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Luong K, Huchital MJ, Saleh AM, Subik M. Management of Distal Fibular Fractures With Minimally Invasive Technique: A Systematic Review. J Foot Ankle Surg 2021; 60:114-120. [PMID: 33172782 DOI: 10.1053/j.jfas.2020.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 05/30/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are extremely common, with isolated distal fibular fractures being the most common variant. The current gold standard in treating unstable distal fibular fractures is open reduction internal fixation. However, with potential risk of wound complications, minimally invasive techniques have been introduced. This systematic review was performed to evaluate the clinical and functional outcomes of varying minimally invasive techniques including minimally invasive plate osteosynthesis, intramedullary (IM) nailing, and IM screw fixation. A comprehensive English literature search on PubMed was performed yielding 543 studies. With specific study selection criteria, a total of 13 articles were selected. After studying the reference of each of the 13 studies, an additional 7 articles were included, resulting in a total of 20 studies reviewed. A total of 8 articles reviewed used IM nailing as the fixation of choice with a total of 211 patients. Of the 211 patients, 33 experienced complications. Six articles using minimally invasive plate osteosynthesis were reviewed with a total of 264 patients. Of the 264 patients, 39 experienced complications. IM screw fixation was used in 6 articles reviewed with a total of 219 patients. There were 30 cases of complications from the 132 patients. Additionally, mean American Orthopedic Foot and Ankle Society hindfoot-ankle scores among all fixation types was 88.4 ± 3.40 whereas the mean Olerud and Molander Score among all fixation types was 76.7 ± 16.58. The results of this study indicate that minimally invasive techniques for fixation of distal fibular fractures can provide excellent functional results with low complication rates compared with traditional open reduction internal fixation.
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Affiliation(s)
- Kenny Luong
- Resident, Saint Mary's General Hospital, Department of Podiatry, Passaic, NJ
| | - Michael J Huchital
- Fellow, North Jersey Reconstructive Foot and Ankle Fellowship, Lyndhurst, NJ.
| | - Ali M Saleh
- Resident, Saint Mary's General Hospital, Department of Podiatry, Passaic, NJ
| | - Michael Subik
- Director, North Jersey Reconstructive Foot and Ankle Fellowship, Lyndhurst, NJ; Residency Director, Saint Mary's General Hospital, Department of Podiatry, Passaic, NJ
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Stake IK, Gregersen MG, Molund M, Östman B. Fibular Rod Osteosynthesis in Ankle Fractures With Compromised Soft Tissue. Foot Ankle Spec 2021; 16:121-128. [PMID: 34142578 DOI: 10.1177/19386400211018075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Complications after plate and screw fixation of ankle fractures are frequently reported in the literature, with a higher rate in patients with advanced age, comorbidities, and poor skin conditions. A reduced complication rate has been reported with intramedullary nailing (IMN) of the fibula; however, the indication has been based on the surgeon's preferences. We report the results after IMN in patients with compromised soft tissue exclusively. METHODS A total of 71 patients with 72 distal fibula fractures were included in this retrospective study. Information about medical history, the ankle injury, treatment, and complications were collected from the medical records. Additionally, the preinjury and 6-week follow-up radiographs were evaluated. RESULTS Postoperative information was available for a minimum of 4.3 years postoperatively or until death. In all, 10 patients had complications related to the nail and required secondary surgery. These included 6 symptomatic hardware issues, 2 construct failures, 1 deep infection, and 1 combined deep infection and construct failure. CONCLUSIONS After IMN of the fibula, 14% of the patients required reoperation. Our results support the previous literature suggesting IMN as an acceptable surgical alternative where the risk of complications with plate and screw fixation is considered too high. Compromised soft tissue is one important indication. LEVEL OF EVIDENCE Level IV: Case series without control.
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Affiliation(s)
| | | | - Marius Molund
- Department of Orthopaedic Surgery, Ostfold Hospital Trust, Graalum, Norway
| | - Bengt Östman
- Department of Orthopaedic Surgery, Ostfold Hospital Trust, Graalum, Norway
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Effects and Anti-rotation Stabilization of the Non-bridging External Fixation for Pronation-Abduction Stage III Ankle Fracture: A Cadaveric Study. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9966344. [PMID: 34046502 PMCID: PMC8128611 DOI: 10.1155/2021/9966344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/20/2021] [Accepted: 04/27/2021] [Indexed: 11/17/2022]
Abstract
Objective This study is aimed at providing a nonbridging external fixation technique with pinning fixation for the pronation-abduction stage III ankle fracture. The secondary purpose was to evaluate its effect on anatomic reduction and fracture fragment stability against cadaveric models' rotation. Method A paired design study was conducted using 14 pairs of the cadaveric model which had been modeled for pronation-abduction stage III ankle fracture. One fracture model from each pair was randomly allocated to receive an open reduction and internal fixation, while the other was reduced and stabilized with the external fixation technique. After the surgery, the antirotational stability tests were performed with external rotation torques of 10 nm, 15 nm, and 20 nm applied, respectively. The postoperation reduction rate and ankle parameters were recorded in anteroposterior and lateral radiographs before and after the antirotational stability experiment. Result The outcomes were assessed according to Burwell-Charnley's radiographic criteria of reduction. It showed no statistically significant differences in reduction between the two groups (P < 0.05). The displacement of lateral fragment following a reduction in the external fixation group was significantly larger than that of the internal fixation group (3.14 ± 0.56 vs. 1.49 ± 0.39, P < 0.05). After applying rotational torques of 10 nm, 15 nm, and 20 nm, the results of other parameters showed no significant differences between the two groups. Conclusion This nonbridging external fixation method with pin fixation of fracture fragments might have the same effect as that of internal fixation on the reduction rate of pronation-abduction stage III ankle fracture.
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Bäcker HC, Vosseller JT. Intramedullary fixation of fibula fractures: A systematic review. J Clin Orthop Trauma 2021; 18:136-143. [PMID: 33996458 PMCID: PMC8102757 DOI: 10.1016/j.jcot.2021.04.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Distal fibula fractures are common injuries that often require open reduction internal fixation. Intramedullary fixation of the fibula has been used historically, and interest has been renewed somewhat recently, although there is limited data assessing outcomes after intramedullary fibular fixation. The purpose of this study was to systematically evaluate the literature as it relates to the clinical and functional outcome after fibular fracture fixation using an intramedullary device. METHODS A literature review on Medline/Pubmed, EMBASE, Cochrane and Google was performed. In total, 1994 abstracts were reviewed of which 30 articles in English, German and French were included, all of which evaluated the clinical and functional outcome after fibular nail osteosynthesis. RESULTS Within the 30 studies, a total of 1116/1380 patients were treated with a fibular nail between 1986 and 2018. In total 11 different devices were investigated. Six articles compared fibular nail versus plate osteosynthesis and in five cases a prospective study was performed. The complication rate varied somewhat widely based on the implants used. The mean union rate was 99.1% with a mean follow-up of 19.0 months. In comparison to plate fixation the nail was superior in terms of complication rate in most studies. No unified assessment of functional outcome was used, and so comparison between studies was difficult. However, good and excellent results were obtained in 73%-100% of patients. CONCLUSION Current data on intramedullary fixation of the fibula is limited and suffers significantly from inconsistency in outcome reporting. It remains to be seen whether the potential advantages of intramedullary implants can both maintain the good results of other implants and improve on some aspects of more commonly used implants. LEVEL OF EVIDENCE III, systematic review.
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Affiliation(s)
- Henrik C. Bäcker
- Department of Orthopaedic Surgery, Columbia University Medical Center, NY, USA,Department of Orthopaedic Surgery, Charité Berlin, UniversityHospital, Berlin, Germany,Corresponding author. Department of Orthopaedic Surgery, Columbia University Medical Center/New York Presbyterian Hospital, 622 West 168th Street PH-11, New York, NY 10032, USA.
| | - J. Turner Vosseller
- Department of Orthopaedic Surgery, Columbia University Medical Center, NY, USA
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Kamin K, Kleber C, Marx C, Schaser KD, Rammelt S. [Minimally invasive fixation of distal fibular fractures with intramedullary nailing]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:104-111. [PMID: 33728477 DOI: 10.1007/s00064-021-00702-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Minimally invasive osteosynthesis of distal fibula fractures serves as a biomechanically stable and soft-tissue-friendly fixation method in the case of an unstable fracture, poor bone quality, and/or critical soft tissue conditions with restoration of the length, axis and rotation of the distal fibula as well as stabilization of the ankle mortise. The goal is to reduce and stabilize the distal fibular fracture in a quick and stable manner that protects the soft tissues in ankle fractures. INDICATIONS Unstable malleolar fractures and fracture dislocations; fibular fractures in combination with distal tibia fractures; critical soft tissue conditions around the ankle. CONTRAINDICATIONS No consent to surgery by the patient. Overall critical (life-threatening) general condition preventing surgery to the extremities. Very narrow medullary canal of the fibula (less than 3 mm, depending on the implant). SURGICAL TECHNIQUE Percutaneous placement of a guidewire into the distal fibular tip, opening the medullary canal and drilling the medullary canal in the distal fragment. Reduction of the axis by introduction of the fibular nail, with additional percutaneous use of reduction clamps for restoration of fibular length and rotation, if necessary. Placement of distal locking screws over the targeting device while maintaining rotation and length, in addition proximal static locking is mandatory to maintain the length of the fibula. In case of residual syndesmotic instability after fracture fixation, syndesmotic screws are inserted through the fibular nail via the aiming device. POSTOPERATIVE MANAGEMENT Following surgery, rest and elevation of the injured leg, and local cooling are indicated. Subsequently, mobilization with partial weight bearing (15-20 kg) in an ankle foot orthosis or plaster/cast for 6 weeks. RESULTS Minimally invasive fibular fixation with an intramedullary nail results in a significantly lower rate of wound healing complications compared with lateral plating. Reported union rates range from 97.4 to 100% with current nail designs. The quality of reduction and functional outcome is comparable to that after plate fixation. A certain learning curve has to be respected.
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Affiliation(s)
- Konrad Kamin
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Christian Kleber
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Christine Marx
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Klaus-Dieter Schaser
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
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The Fibular Intramedullary Nail Versus Locking Plate and Lag Screw Fixation in the Management of Unstable Elderly Ankle Fractures: A Cadaveric Biomechanical Comparison. J Orthop Trauma 2020; 34:e401-e406. [PMID: 33065664 DOI: 10.1097/bot.0000000000001814] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the biomechanical failure properties of the fibular intramedullary nail with locking plate and lag screw fixation in the management of unstable elderly distal fibular fractures. METHODS Twelve fresh-frozen cadaveric lower limbs (6 matched-pairs) were studied. A simulated OTA/AO 44-B fracture was created, then randomly allocated within each pair to intramedullary nail or locking plate fixation supplemented with an interfragmentary lag screw. The limbs were secured with the foot rigidly held in 20 degrees of supination, loaded to 700N and subjected to progressive external rotation until failure. RESULTS The mean specimen age was 86.5 years (61-97). Mean torque to failure was greater in the intramedullary nail group, but did not reach statistical significance (23.5 N·m vs. 21.6 N·m; P = 0.463). The nail failed at a significantly greater angle of rotation compared with plate fixation (66.5 degrees vs. 53.3 degrees; P = 0.046). There was no significant difference between the groups with respect to construct stiffness (P = 0.673) or energy absorbed (P = 0.075). The locking plate specimens failed through plate and screw construct pull off at the implant-bone interface. In contrast, the intramedullary nail specimens failed at the lateral ligament complex, whereas the fracture-implant construct remained intact. CONCLUSION Intramedullary nailing and locking plate fixation have similar biomechanical characteristics when tested to failure. The benefits of the minimally invasive surgery offered by the intramedullary nail make it an attractive implant in the management of these patients.
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Daniels TR, Wilson IR, Fu JM. What's New in Foot and Ankle Surgery. J Bone Joint Surg Am 2020; 102:856-865. [PMID: 32187125 DOI: 10.2106/jbjs.20.00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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Al-Obaidi B, Wiik AV, Bhattacharyya R, Mushtaq N, Bhattacharya R. Fibular nails for open and closed ankle fractures: Results from a non-designer level I major trauma centre. J Orthop Surg (Hong Kong) 2020; 27:2309499019832420. [PMID: 30803314 DOI: 10.1177/2309499019832420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIM To evaluate the outcome of a fibular nail in the treatment of open and closed unstable ankle fractures in a non-designer centre. METHODS In a retrospective cohort study, a total of 39 ankle fractures (14 open and 25 closed) treated with a locking fibular nail were evaluated between 2012 and 2015 in a non-designer level I major trauma centre. Post-operative radiographs were analysed to assess the quality of reduction (McLennan and Ungersma marking system), fracture union and complications. Three patient reported outcome scores (Olerud and Molander score (OMAS), American Association of Orthopaedic Surgeons (AAOS) foot and ankle score and 12-Item Short Form Survey (SF-12)) were collected to obtain an overall measure of the patient's physical and mental outcome. RESULTS The adequacy of reduction data was available for 38 of 39 cases; 33 (87%) achieved good, 3 (8%) fair and 2 (5%) poor ratings, based on the McLennan and Ungersma marking system. Thirty-five (12 open and 23 closed) patients were available for initial follow-up. Five (14.3%) of 35 had documented complications (2 of 12 in the open cohort and 3 of 23 in the closed cohort). All fibular fractures treated with the fibular nail went on to unite. Twenty-three (66%) of 35 patients were available at 1-year follow-up for measurement of objective outcome. The combined mean OMAS for both groups was 53.7 (0-85) with statistically better results (59.5 (25-85) vs. 37.3 (0-75)) in favour of the closed versus open injuries, respectively. The mean AAOS score was also statistically better for the closed group than the open, 70.3 (30-95) versus 46.6 (20-77), respectively. The mean SF-12 score (physical component) was 40 (21.6-52.4) in the closed group versus 36.1 (19.4-51.5) in the open group; the mean mental component was 42.5 (26.6-54.3) in the closed group versus 38.8 (28.4-60.5) in the open group, these however were not statistically different. CONCLUSION Fibular nails are an effective alternative for the treatment for both closed and open unstable ankle fractures with soft tissue compromise.
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Affiliation(s)
- Bilal Al-Obaidi
- Department of Trauma and Orthopaedics, Division of Surgery and Cancer, Imperial College Healthcare NHS Trust, North West London Major Trauma Centre, London, UK
| | - Anatole Vilhelm Wiik
- Department of Trauma and Orthopaedics, Division of Surgery and Cancer, Imperial College Healthcare NHS Trust, North West London Major Trauma Centre, London, UK
| | - Rahul Bhattacharyya
- Department of Trauma and Orthopaedics, Division of Surgery and Cancer, Imperial College Healthcare NHS Trust, North West London Major Trauma Centre, London, UK
| | - Nadeem Mushtaq
- Department of Trauma and Orthopaedics, Division of Surgery and Cancer, Imperial College Healthcare NHS Trust, North West London Major Trauma Centre, London, UK
| | - Rajarshi Bhattacharya
- Department of Trauma and Orthopaedics, Division of Surgery and Cancer, Imperial College Healthcare NHS Trust, North West London Major Trauma Centre, London, UK
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20
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Intramedullary nailing as an alternative to plate fixation in patients with distal fibular fracture. Orthop Traumatol Surg Res 2020; 106:149-154. [PMID: 31812634 DOI: 10.1016/j.otsr.2019.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/19/2019] [Accepted: 10/07/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND We examined whether the intramedullary nailing (IMN) can be used as an alternative modality to the plate fixation (PF) in patients with distal fibular fracture with displaced fragments. PATIENTS AND METHODS The eligible patients of two treatment arms (IMN group: n=30 and the group: n=31) were evaluated at 3, 6, 9 and 12 months postoperatively, for which functional outcome measures include differences in the American Orthopaedic Foot and Ankle Society Scores (AOFAS) and the Olerud Molander Ankle Scores (OMAS) between the two groups. In addition, radiological outcome measures include differences in radiological outcome scores at 12 months between the two groups. Differences in the percentage of frequency of postoperative complications between the two groups served as safety outcome measures. RESULTS At 3 months, the AOFAS and OMAS were significantly higher in the IMN group as compared with the PF group (p<0.0001 and p=0.0177, respectively). At 6 months, the AOFAS were significantly higher in the IMN group as compared with the PF group (p=0.0255). But there were no significant differences in the OMAS between the two groups (p=0.1077). At 9 and 12 months, there were no significant differences in the AOFAS and OMAS between the two groups (p=0.4334 and 0.3227, respectively at 9 months and p=0.8731 and 0.7610, respectively, at 12 months). These results indicate that the IMN group achieved a faster recovery as compared with the PF group. At 12 months, the radiological outcome scores were 3.67±0.60 in the IMN group and 3.71±0.52 in the PF group (p=0.7816). All the patients of each group achieved a bony union at 12 months. At 12 months, the percentage of frequency of postoperative complications was significantly lower in the IMN group as compared with the PF group (p=0.0227). CONCLUSIONS The IMN might be considered as an alternative surgical modality to the PF in patients with distal fibular fracture with displaced fragments. But further large-scale, multi-center studies are warranted to establish our results.
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Abstract
BACKGROUND Intramedullary implants have been used historically in long bone fractures with success. In recent years, a variety of intramedullary implants for the treatment of fibular fractures have been investigated. These various implants have not been assessed together in a cohesive manner. In this review, we assess implants used for intramedullary fixation of fibular fractures with respect to implant design and clinical results. METHODS A comprehensive systematic literature review for intramedullary implants in fibular fractures was performed. All publications that assessed intramedullary fibular implants were reviewed. In total, 11 different intramedullary nails were found. Clinical results obtained from these studies were reviewed. RESULTS The intramedullary implants used for fibular fracture fixation generally fell into one of 3 categories: an unlocked longitudinal strut, an implant roughly equivalent to a large screw, or a more traditionally locked intramedullary nail. Reported clinical results were generally good, although inconsistent outcome reporting greatly limited comparison between studies. Complication rates varied with the implants but were generally low. CONCLUSION Intramedullary implants for fibular fracture stabilization have changed over the years to improve stability. Although clinical results are limited, data suggest that these implants are safe and can potentially approximate more traditional implants. LEVEL OF EVIDENCE Level II, systematic review.
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Affiliation(s)
- Henrik C Bäcker
- Department of Orthopaedic Surgery, Columbia University Medical Center, NY, USA
| | - J Turner Vosseller
- Department of Orthopaedic Surgery, Columbia University Medical Center, NY, USA
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Ebraheim NA, Vander Maten JW, Delaney JR, White E, Hanna M, Liu J. Cannulated Intramedullary Screw Fixation of Distal Fibular Fractures. Foot Ankle Spec 2019; 12:264-271. [PMID: 30091366 DOI: 10.1177/1938640018790082] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Background: Open reduction and internal fixation (ORIF) methods, primarily plates and screws, remain the standard of treatment for distal fibular fractures. This study evaluates the use of a cannulated intramedullary screw as a minimally invasive treatment method for distal fibular fractures, which has not been reported in the current literature. Methods: This retrospective study included 45 patients with distal fibular fractures treated with cannulated intramedullary screw fixation. All patients included in the cohort had a soft-tissue condition and/or comorbidity. The mean age was 54 years. The Weber classification system was used to assess the type of fracture. Average time to union, average time to weight bearing, and complications were monitored. Results: Reduction quality criteria were collected using previously published guidelines. Accordingly, reduction was determined to be good in 25 cases, fair in 15, and poor in 5. A low complication rate of 4% was reported. Average time to union was 10 weeks (range = 8-36 weeks), whereas average time to weight bearing was 14 weeks (range = 8-40 weeks). Conclusion: Cannulated intramedullary screw fixation can serve as a minimally invasive, safe, and satisfactory treatment for distal fibular fractures with resulting high union rates and low complication rates. Levels of Evidence: Level IV: Retrospective, case series.
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Affiliation(s)
- Nabil A Ebraheim
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | | | - Joshua R Delaney
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Erik White
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Maged Hanna
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Jiayong Liu
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
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Bazin I, Armendariz M, Marcheix PS, Pichon M, Fredon F, Mabit C, Mathieu PA. A computed tomography study of the fibula: morphology, morphometry, intramedullary anatomy, application prospects on intramedullary nailing. Surg Radiol Anat 2019; 41:681-687. [PMID: 30993418 DOI: 10.1007/s00276-019-02213-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The intramedullary percutaneous pinning in fractures of the lateral malleolus is a technique of osteosynthesis that can reduce complications of ORIF. Our study describes the morphology and the morphometry of the fibula, in particular intramedullary, so as to specify the best fibular nail features. METHODS We conducted a retrospective study on CT acquisitions of fibulae in vivo. We studied total length, and the distal malleolar angle. Regarding intramedullary morphology, six axial study levels were defined. Each level was assigned a morphometric classification (oval, triangular, quadrangular or irregular), and a measure of the diameter of the cavity. The distance between the smaller diameter and the malleolar tip was investigated. RESULTS We included 50 patients for 97 fibulae. The average age was 66.5 years. The irregular morphology type was the most frequently found. The average length was 370.5 mm (SD = 18.1; CI 95% [366.9; 374.1]), the average distal malleolar angle was 163.5° (SD = 3.7; CI 95% [162.7; 164.2]). The average minimal intramedullary diameter at malleolus level was 3.2 mm (SD = 1.2; CI 95% [3.0; 3.5]), with a minimum size reaching 95.8 mm (SD = 13.8; CI 95% [93.0; 98.5]) of the malleolar tip. CONCLUSIONS The analysis of morphological parameters of the fibula, in particular the lateral malleolus and intramedullary morphology is necessary for the design of a morpho-adapted nail. Interpersonal variability must be taken into account by the implant industry to offer nails of suited lengths and diameters.
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Affiliation(s)
- I Bazin
- Centre Hospitalier Universitaire de Limoges Dupuytren, 2 Avenue Martin Luther King, 87000, Limoges, France.
| | - M Armendariz
- Centre Hospitalier Universitaire de Limoges Dupuytren, 2 Avenue Martin Luther King, 87000, Limoges, France
| | - P S Marcheix
- Centre Hospitalier Universitaire de Limoges Dupuytren, 2 Avenue Martin Luther King, 87000, Limoges, France
| | - M Pichon
- Centre Hospitalier Universitaire de Limoges Dupuytren, 2 Avenue Martin Luther King, 87000, Limoges, France
| | - F Fredon
- Centre Hospitalier Universitaire de Limoges Dupuytren, 2 Avenue Martin Luther King, 87000, Limoges, France
| | - C Mabit
- Centre Hospitalier Universitaire de Limoges Dupuytren, 2 Avenue Martin Luther King, 87000, Limoges, France
| | - P A Mathieu
- Centre Hospitalier Universitaire de Limoges Dupuytren, 2 Avenue Martin Luther King, 87000, Limoges, France
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Prissel MA, Daigre JL, Brandão RA, Philbin TM, Hyer CF, Berlet GC. Cross-Sectional Analysis of the Distal Fibular Intramedullary Canal: A Cadaveric Evaluation. Foot Ankle Spec 2018; 11:1938640017751190. [PMID: 29361841 DOI: 10.1177/1938640017751190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fractures of the distal fibula secondary to rotational ankle injuries are one of the most common injuries requiring surgical intervention. The aim of this study was to describe the anatomy of the distal fibular medullary canal as a means of aiding in surgical management with an intramedullary device. Twenty fresh cadaveric below-knee specimens (group 1, 10 in 2015, group 2, 10 in 2016) were dissected to expose the distal fibular. Fifteen (10 mm each) segments were sectioned with a sagittal saw from the distal tip proximally and measured with a digital caliper. In group I, the widest and narrowest fibular diameter was at the 20-mm interval (mean 15.02 mm) and 90-mm interval (mean 3.51 mm), respectively. From 70 to 120 mm, the mean diameter was less than 4.0 mm. In group 2, the widest and narrowest diameter was at the 20-mm interval (mean 15.05 mm) and 100-mm interval (mean 4.33 mm), respectively. From 70 to 140 mm, the mean diameter was less than 5.0 mm. The combined mean diameter at the 60- to 80-mm intervals were 4.99 ± 1.70, 4.35 ± 1.63, and 4.02 ± 1.35 mm, respectively. Based on our investigation, we propose an intramedullary device diameter of 4.5 to 5.0 mm in diameter with a length of 60 to 80 mm may provide most appropriate bony purchase to achieve acceptable cortical contact for expected osseous compression. LEVELS OF EVIDENCE Level IV: Cadaveric case series.
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Affiliation(s)
- Mark A Prissel
- Orthopedic Foot and Ankle Center, Westerville, Ohio (MAP, RAB, TMP, CFH, GCP)
- Decatur Orthopaedic Center, Decatur, Alabama (JLD)
| | - Justin L Daigre
- Orthopedic Foot and Ankle Center, Westerville, Ohio (MAP, RAB, TMP, CFH, GCP)
- Decatur Orthopaedic Center, Decatur, Alabama (JLD)
| | - Roberto A Brandão
- Orthopedic Foot and Ankle Center, Westerville, Ohio (MAP, RAB, TMP, CFH, GCP)
- Decatur Orthopaedic Center, Decatur, Alabama (JLD)
| | - Terrence M Philbin
- Orthopedic Foot and Ankle Center, Westerville, Ohio (MAP, RAB, TMP, CFH, GCP)
- Decatur Orthopaedic Center, Decatur, Alabama (JLD)
| | - Christopher F Hyer
- Orthopedic Foot and Ankle Center, Westerville, Ohio (MAP, RAB, TMP, CFH, GCP)
- Decatur Orthopaedic Center, Decatur, Alabama (JLD)
| | - Gregory C Berlet
- Orthopedic Foot and Ankle Center, Westerville, Ohio (MAP, RAB, TMP, CFH, GCP)
- Decatur Orthopaedic Center, Decatur, Alabama (JLD)
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