A comparison of bone union and complication rates between locking and non-locking plates in distal fibular fracture: Retrospective study of 106 cases

A comparison of outcomes of locking versus non-locking plate fixation for the distal fibula fractures: a systematic review and meta-analysis

PURPOSE

A locking plate (LP) or non-locking plate (NLP) can be used for distal fibula fracture fixation. However, the advantages of LP over NLP in patients with distal fibula fractures are not clear. In terms of indications, the role of the two plates probably differs; however, to draw comparative conclusions, we conceptualized this systematic review and meta-analysis of studies that directly compared the two plates, wherein both groups' indications and baseline parameters were similar.

METHODS

An electronic literature search was performed using PubMed/Medline, Embase, Scopus, and Cochrane Library databases for studies comparing the LP versus NLP fixation for the lateral malleolus fracture. A total of 18 studies were included in qualitative and quantitative analysis. A subgroup analysis was performed for patients aged < 55 years and patients aged > 55 years. The statistical analysis was performed by Review Manager Software version 5.4.1.

RESULTS

A meta-analysis of 4243 fractures was performed across 18 studies. The rate of fracture union and overall complication rates did not differ between the two fixation groups with an OR of 0.71 (95% CI 0.26, 1.96, p = 0.51 and 1.11 (95% CI 0.84, 1.47, p = 0.47, respectively. There is no difference in the reoperation rate due to minor or major complications between the two groups. There was no difference in functional outcome (MD -0.85, with 95% CI -5.63, 3.93, p = 0.73), but NLP has a shorter surgical duration (MD 3.0, with 95% CI 0.26, 5.75, p = 0.03). A leave-one-out sensitivity analysis performed for overall complications affected the final outcome of the meta-analysis.

CONCLUSION

This meta-analysis demonstrates no clear benefit in selecting LP over NLP for the fixation of lateral malleolus fractures.

Locking versus nonlocking plates for the treatment of posterior malleolar ankle fractures: A retrospective cohort study and cost analysis

BACKGROUND

We hypothesized that, as posterior malleolar ankle fractures usually present one or two main fragments, the buttress plating principle can be successfully achieved either with conventional nonlocking or anatomic locking posterior tibia plates, and no clinical differences should be found. The aim of this study was to evaluate the outcomes of posterior malleolar ankle (PM) fractures treated with conventional nonlocking (CNP) or anatomic locking plates (ALP), and also to compare both constructs in terms of crude costs.

METHODS

A retrospective cohort study was designed. CNP was used in 22 patients and ALP was used in 11 patients. American Orthopedic Foot and Ankle Society (AOFAS) score was registered at four weeks, 3-6 months, 12 and 24 months to assess all patients' functional status. The primary outcome was ankle and hindfoot AOFAS score at 12 months follow-up visit. All complications, radiographic evaluation and implant construct costs were also registered and compared. The average follow-up was 25.4 (range, 12-42) months.

RESULTS

No significant difference was observed between both cohorts, in terms of AOFAS score and complication rate (P > .05). We found that ALP construct is 17 times more expensive than CNP construct in our institution (P < .001).

CONCLUSION

Anatomic locking posterior tibial plates may be an interesting device when poor bone quality is present or when a true multifragmentary pilon fracture is faced. Anatomic locking posterior tibia plate should not become a regular implant for any PM fracture since equivalent clinical and radiological results were obtained in our study using CNP with a significant reduced cost.

Trends of incidence and treatment strategies for operatively treated distal fibula fractures from 2005 to 2019: a nationwide register analysis

INTRODUCTION

Valid epidemiological data about distal fibular fractures and their treatment strategies are missing. Innovative osteosynthesis techniques were introduced and improved during the past 15 years. The aim of this study was to investigate the epidemiologic development and the implementation of new treatment strategies in a nationwide register in Germany over a period of 15 years.

MATERIALS AND METHODS

Data of the German Federal Statistical Office from 2005 until 2019 were screened. Adults with a fracture of the distal fibula were included. Data were separated for gender, age and treatment strategy.

RESULTS

During the past 15 years, there was a steady annual incidence of distal fibula fractures of 74 ± 32 per 100,000 people without any significant changes (p = 0.436). 60.1% ± 0.6% of all fractures occurred in females. The annual incidence for male was nearly constant over the different age groups, whereas for female, there was a clear increase in incidence above the age of 40. Whereas 66% of fractures in between 20 and 30 years of age occurred in male, approximately 70% of fractures above the age of 60 occurred in females. The relative quantity of locking plates increased from 2% in 2005 to 34% in 2019. In 2019, only 1.02% of the patients were operated with an intramedullary nail.

CONCLUSIONS

Operatively treated distal fibular fractures revealed an age dependent increase in incidence in postmenopausal women compared to younger females. Regarding the treatment strategy, there was an increase in application of locking plates. The data implicate a typical fragility fracture related age and gender distribution for distal fibula fractures.

Similar Clinical Outcome in Locking and Conventional Plate Osteosynthesis for the Treatment of AO 44-B2 Ankle Fractures

INTRODUCTION

Biomechanical studies have proved that locking plates have better primary stability besides versatility regarding fracture pattern while reducing bone contact and bridging the gap, whereas conventional nonlocking plates (plus lag screw) depend on bone-plate compression. The clinical benefit of locking plates over nonlocking plates remains unanswered, however. Therefore, this retrospective cohort study was set up to test the hypothesis that the use of locking plates for unstable ankle fractures will result in fewer re-displacements, superior bony healing, and functional and clinical outcomes better than observed in the nonlocking cohort.

METHODS

Bimalleolar ankle fractures (AO 44-B2) without syndesmotic injury treated with either a locking or a nonlocking plate were included. Groups were compared for complications, bone healing, secondary dislocation, progressions of osteoarthritis, and clinical outcome using patient-reported outcome measures.

RESULTS

Data revealed no clinical outcome differences (Olerud-Molander Ankle Score: nonlocking 88.2 ± 14.4, locking 88.8 ± 12.3, P = .69, robust two 1-sided test for equality (RTOST): P = .03; American Orthopaedic Foot and Ankle Score: nonlocking 91.2 ± 12.9, locking 91.8 ± 11.3, P = .96, RTOST: P = .04). Nevertheless, a significant postoperative progression of osteoarthritis was detected in both groups (P = .04). This was independent of implant (P = .16). Although difference was not significant, locking plates were preferred in older (P = .78) and sicker patients (P = .63) and in cases with severer osteoarthritis (P = .16), and were associated with a higher complication rate (P = .42) and secondary dislocation (nonlocking 9.4%, locking 18.2%; P = .42). Re-displacement, however, was not a compelling reason for revision.

CONCLUSIONS

The present study shows statistically significant equality of both types of implants. Contrary to our expectation, locking plates seemed to be associated with a higher risk for re-displacement. Overall, the use of either locking or nonlocking plates for unstable AO 44-B2 fractures is safe and successful despite significant progression of osteoarthritis.

LEVEL OF EVIDENCE

III, Retrospective observational cohort study.

Resumption of complete weight bearing after osteosynthesis of bimalleolar fractures using locking plates

INTRODUCTION

Bimalleolar fractures represent 9% of fractures and affect 187/100,000 people per year. The gold standard for osteosynthesis is a one-third tubular or lateral locking plate and compression screwing or use of tension band wiring, with complete weight bearing planned around the 6th week. The development of locking plates seems to allow earlier resumption of weight bearing. The objective of our study was to evaluate the clinical and radiological results after internal fixation of bimalleolar fractures using locking plates with complete weight bearing authorized from the outset. The hypothesis was that this does not predispose to cutaneous or mechanical complications.

HARDWARE AND METHOD

A continuous multi-operator retrospective study was performed. The clinical and radiological data of 55 patients operated on for bimalleolar fractures were collected. All underwent osteosynthesis with medial and lateral locking plates with authorization for weight bearing from the outset.

RESULTS

Complete weight bearing was resumed at 27.4 days 14.7 [7-60] postoperatively. No non-union or malunion was found. Two patients presented with delayed medial healing without the need for hardware removal. Two patients required removal of the lateral Plate 1 month postoperatively due to infection. Seven patients presented with discomfort related to hardware, justifying its removal at 1 year. The Kitaoka score at 1 year was 94.6 7.7 [71-100].

CONCLUSION

The use of medial and lateral locking plates in bimalleolar fractures associated with complete weight bearing authorized from the outset allows complete consolidation. There was no increase in cutaneous or mechanical complications.

LEVEL OF EVIDENCE

IV, retrospective study.

Three internal fixation methods for Danis-Weber-B distal fibular fractures: A biomechanical comparison in an osteoporotic fibula model

A common agreement for the surgical treatment of osteoporotic ankle fractures has not been defined yet although locking plates are preferred for fractures with poor bone quality. This study aims to evaluate the mechanical stability of locked and conventional plates on osteoporotic Danis-Weber-B-fibula fracture models. Fractured custom-made osteoporotic fibulae were treated with neutralization plate plus lag screw, locking plate plus lag screw, or a standalone locking plate. Load until failure was applied mimicking single-leg stance. Stiffness, failureload, and interfragmentary movements were investigated. Stiffness, failureload and axial fragment movement showed no significant differences among groups. Shear movements and fragment rotation around the shaft of the neutralization plate were on average twice as high as those of the locking plates. Although no superiority was shown for overall mechanical performance, the locking plate groups exhibited higher shear and rotational stability than the neutralization plate.

Risk of Reoperation in Simple Ankle Fracture Surgery When Comparing Locking Plate With Nonlocking Plate

Locking plates were initially designed to provide improved stability to ankle fractures with poor bone quality but are currently widely used. The aim of this study was to compare the reoperation risk when using locking plates compared with nonlocking plates in patients with simple ankle fractures. This study was a population-based register study. Data regarding patients with AO type 44A1/2 and 44B1/2 injuries who were treated with either locking or nonlocking plates were obtained from the Danish Fracture Database. The follow-up period was 24 months. Major complications were defined as complications requiring surgical intervention, with the exception of simple hardware removal 6 weeks after primary surgery, which was defined as a minor complication. Multivariate regression analysis was performed to determine relative risk (RR), adjusted for age, sex, American Society of Anesthesiologists physical status classification (ASA)-score, and level of the surgeon's experience. A total of 2177 ankle fractures were included, among which 718 (33%) were treated with locking plates, and 1459 (67%) were treated with nonlocking plates. Data were linked with the Danish National Patient Registry to ensure complete information was obtained regarding reoperations, which were divided into major and minor complications. In both groups, the risks for major and minor complications were 3% and 22%, respectively, resulting in adjusted RRs of 1.00 (0.66; 1.66) for major reoperation comparing locking with nonlocking plates and 0.92 (0.76; 1.11) for minor reoperations. We conclude that no significant association with reoperation exists for locking compared with nonlocking plates among patients with surgically treated simple ankle fractures.

Operative Fixation of Lateral Malleolus Fractures With Locking Plates vs Nonlocking Plates: A Systematic Review and Meta-analysis

BACKGROUND

The exact benefit of locking plates over nonlocking plates in patients with lateral malleolus fractures remains unclear. The primary aim of this study was to compare the functional outcome of locking plates vs nonlocking plates in patients with a lateral malleolus fracture. The secondary aims were to compare the number of complications and hardware removals and to compare whether results differed for older patients and for patients treated with anatomical locking plates.

METHODS

The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for studies comparing locking plates with nonlocking plates in patients with fixated lateral malleolus fractures. All included studies were assessed on their methodologic quality using the MINORS. Subgroup analyses were performed on older patients and patients treated with anatomical locking plates.

RESULTS

A total of 11 studies were included. The meta-analysis showed that functional outcome did not differ between patients treated with locking plates and nonlocking plates (MD 2.38, 95% CI -2.71 to 7.46). No difference in both complication rate (OR 1.10, 95% CI 0.74-1.63) and the amount of hardware removals (OR 0.77, 95% CI 0.52-1.14) was found. Even after analyzing older patients and patients treated with anatomical locking plates, no benefit was shown.

CONCLUSION

This meta-analysis demonstrates no clear benefit in selecting locking plates over nonlocking plates in the treatment of lateral malleolus fractures.

CLINICAL RELEVANCE

Locking plates are increasingly being used in the treatment of lateral malleolus fractures. Biomechanical studies have shown an increased stability with use of locking vs nonlocking plates. This clinical review does not support a benefit of use of locking plates for these fractures.

Minimally invasive plate osteosynthesis using the oblong hole of a locking plate for comminuted distal fibular fractures

Background

Nonunion is a rare complication for distal fibular fractures. However, when there is a high degree of comminution, nonunion may occur. In this article, we describe a novel technique that uses the oblong hole of a locking plate to lengthen the fibula for fracture reduction. This technique is straightforward and allows for easy control of the comminuted fracture to restore length and rotation at the time of plate application without opening the fracture site.

Methods

Thirty-five consecutive patients, who were treated with the minimally invasive plate osteosynthesis (MIPO) technique for comminuted distal fibular fractures were retrospectively studied. The study included 19 men and 16 women, with a mean age of 47.0 years (range, 20 to 72). There were 3 lateral malleolar fractures with deltoid injury, 11 bimalleolar fractures, 7 trimalleolar fractures, and 14 distal tibiofibular fractures. The quality of fracture reduction was assessed by comparing the radiologic parameters (fibular length, talocrural angle, and medial clear space) between the affected ankle and the contralateral uninjured ankle.

Results

Two patients were not reachable and 5 declined to visit the clinic. For these 7 patients, the latest outcomes that were measured prospectively were used. Postoperative radiographs showed well-aligned ankle mortise, with fibular length restoration. The mean Olerud-Molander ankle score was 82.1 ± 10.7 at a mean of 27.2 months (range, 12 to 58). There was one case of nonunion and one case of superficial peroneal nerve injury.

Conclusion

The MIPO technique, using the oblong hole of a locking plate, achieved satisfactory restoration of length and rotation, bone union, and clinical outcomes for the comminuted distal fibular fractures.