Fixation of distal fibula fractures: an update

Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures

PURPOSE

To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants.

METHODS

In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records.

RESULTS

Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group.

CONCLUSION

Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.

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.

Can Anterior Knee Pain Be Explained by Patella Position After Infrapatellar Tibia Intramedullary Nailing?

OBJECTIVE

The objective of this study is to investigate the postoperative position of the patella and its relationship with anterior knee pain in patients operated with infrapatellar reamed tibia intramedullary nailing (IMN).

MATERIALS AND METHODS

 Patients who underwent tibia IMN between 2019 and 2022 and who had anterior knee pain in their postoperative follow-up at least two outpatient clinic controls with an interval of at least one month were examined. Patellar height indices (Insall-Salvati, Blackburne-Peel, Caton-Deschamps, and modified Insall-Salvati) and sagittal angulation (patella-patellar tendon angles) were measured on the lateral direct radiographs of the patients in semi-flexion. As a control group, measurements were made on the contralateral intact extremity radiographs of the same patients.

RESULTS

 There was no significant difference in patellar height indices between the fractured and intact sides in any of the patients (p = 0.588; p = 0.747; p = 0.446; p = 0.573, respectively). When the sagittal angulations were analyzed, a significant difference was found between the fractured and intact sides of the patients (p = 0.048), resulting in an approximate three-degree change.

CONCLUSION

 Patellar sagittal balance has been identified as one of the contributing factors to the development of anterior knee pain following reamed tibial IMN. Further biomechanical and comprehensive clinical studies are needed on this subject.

The safe zone of distal fibula was determined based on the classification of lateral malleolus fossa

BACKGROUND

Lateral malleolus fractures are very common, and the distal fibular geometry is complex. This study aimed to classify the lateral malleolus fossa (MF) into different types by characterizing the lateral MF imaging morphology and exploring the relationship between the lateral MF and internal fixation position after distal fibula fractures.

METHODS

Anteroposterior CT reconstruction was performed on 248 subjects. After reconstruction, the deepest point of the lateral MF was located, and then, the cross-sectional shape of the lateral MF was observed and classified.

RESULTS

According to the morphology of the CT cross section, the lateral MF was divided into three types: type C (43.1%), type V (32.2%), and type Flat (24.7%). Type V (3.98 ± 0.82) was significantly longer than type C(2.83 ± 0.54) and type Flat (1.84 ± 0.42) in cd. Similarly, in ∠α, Type Flat(136.31 ± 9.63) was the largest, followed by type C (116.51 ± 8.79), and type V (89.31 ± 9.07) was the smallest. Other measurements were not found any significant differences between the above.

CONCLUSION

According to the morphology of the CT cross section, the lateral MF was divided into three types: type C, type V and type Flat. Type V is most likely to be invaded when fixing the distal fibula. Screws less than 9 mm should be selected when fixing, and screws no more than 10 mm should be selected when there are type C and type Flat of MF.

Indications for retrograde intramedullary screw fixation of the distal fibula: a retrospective cohort series

Introduction

Ankle fractures are a common orthopaedic injury that often require surgical fixation. Because the comorbid population in the United States continues to survive longer, it has become routine to treat comorbid patients with unstable ankle fractures. The literature has identified comorbidities known to increase the risk of ankle fracture complications to include age 55 years or older, body mass index >29.9, polytrauma, open fractures, diabetes mellitus, smoking, peripheral neuropathy, and alcohol use.

Methods

We retrospectively reviewed 37 patients who received retrograde intramedullary screw fixation of the distal fibula, all of whom had preexisting conditions known to increase the rate of postoperative complications.

Results

Thirty-seven patients were included in this study, of whom 36 (97.3%) went on to union. Six of 37 patients (16.2%) had complications although only one (2.7%) was due to inadequate fixation. The average time to weight-bearing as tolerated was 57.2 days (15-115 days). Two patients (5.4%) had symptomatic instrumentation requiring removal after union. Two patients (5.4%) had delayed union of the distal fibula, which responded to the use of a bone stimulator. One patient (2.7%) developed a nonunion which led to chronic subluxation of the ankle joint. One patient (2.7%) had a minor medial ankle wound complication that was treated with oral antibiotics and local wound care.

Conclusions

Retrograde intramedullary screw fixation of the distal fibula is a viable alternative to plate and screw fixation in patients with unstable ankle fractures who have known risk factors for increased complications. However, not all distal fibula fractures are amenable to this fixation method.

Level of Evidence

Level III retrospective cohort study.

Searching for a New Parameter in the Healing of Tibia Pilon Fractures: Fracture Area Measurement

BACKGROUND

Tibia pilon fractures are associated with high complication rates, decreased quality of life, and low patient satisfaction. Although many factors such as reduction quality and soft-tissue coverage have been identified, researchers continue to investigate the factors that affect healing in tibia pilon fractures. Our objective was to investigate the effect of initial fracture crack width and displacement degree on clinical functional results in tibia pilon fractures.

METHODS

In this retrospective cohort study, 40 patients with Arbeitsgemeinschaft für Osteosynthesefragen and Orthopaedic Trauma Association type 43B and 43C tibia pilon fractures and operated on through the extensile anteromedial approach were analyzed. The demographic data of the patients, injury mechanisms, fracture type, reduction quality, clinical results, and postoperative complications were recorded. To evaluate the objective quantity of initial fracture crack width and displacement, a new parameter was defined: "fracture area." All measurements were conducted using a feature from the picture archiving and communication system on anteroposterior and lateral radiographs taken separately in standard fashion.

RESULTS

With an average follow-up period of 29.2 months (range, 24-40 months), 34 patients (85%) had excellent or good results, whereas only two patients (5%) had poor clinical results. Age, injury mechanism, and reduction quality have a significant relationship with Maryland Foot Score (P < .001, P < .037, and P < .001, respectively). Preoperative fracture area, measured on both the anteroposterior and the lateral views, are significantly related to both Ovadia-Beals Score and Maryland Foot Score (P < .001 for each).

CONCLUSIONS

Preoperative fracture area measurement has a major effect on healing of tibia pilon fractures. Increased initial fracture area is correlated with poor clinical functional results. High-energy injuries, older age, and poor reduction quality are also related to worse clinical outcomes.

Fibula Nailing: A Retrospective Review of 110 Consecutive FibuLock Nails

OBJECTIVES

To evaluate the treatment of unstable lateral malleolar fractures using a fibula nail with both proximal and distal locking capabilities.

DESIGN

Retrospective review of 110 single-surgeon consecutive fibula nails.

SETTING

Single-surgeon, private practice community hospital.

PATIENTS/PARTICIPANTS

One hundred ten fractures, 92 OTA/AO 44B and 18 OTA/AO 44C.

INTERVENTION

FibuLock fibula nail (Arthrex, Naples, FL).

MAIN OUTCOME MEASUREMENTS

Demographic, operative, clinical, and radiographic outcome data.

RESULTS

One hundred two patients/102 fractures met criteria. Ninety percent had a f/u of ≥12 months (mean 12.2 months). All fractures healed. There were no superficial or deep infections, no nonunions, or malunions. Two fractures required conversion to plate fixation intraoperatively because of excessive comminution which precluded the use of a nail, while one patient sustained an iatrogenic superficial peroneal nerve neuroma. No patients reported implant irritation, and none have required implant removal.

CONCLUSION

Fibula nails with proximal locking capabilities offer an alternative to plating with the potential for lower complication rates and lower need for implant removal.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of results of three different patient-based assessment scales in surgically treated adult ankle fractures

Purpose: The aim of this study was to evaluate the post-operative clinical and radiological results of ankle fractures, using three different patient-reported outcome measurements (PROM) and to analyze the results and compatibility of the PROMs. Materials and Methods: A total of 77 patients were followed up prospectively. Demographic data, fracture side, trauma mechanisms, fracture types, post-operative splint times, initiation of full weight bearing time, and complications were recorded. All patients were evaluated according to the AOFAS, Ankle-Hindfoot Rating Scale, Weber Scoring and Freiburg Scale, at the first-year follow-ups. Results: The results were good in 57 patients (74%) and poor in 20 patients (26%), according to the AOFAS Scale; excellent in 51 patients (66.2%), good in 12 patients (15.6%) and poor in 14 patients (18.2%) according to the Weber Scoring, and excellent in 50 patients (64.9%), good in 12 patients (15.6%) and poor in 15 patients (19.5%) according to the Freiburg Scale. The results of the PROMs were found to be compatible with each other. Significant relationship was found between the development of complications and the AOFAS Scale and Weber Scoring, and between older age and Weber Scoring. Conclusion: The results of the AOFAS Scale, Weber Score and Freiburg Scales are compatible with each other and can be safely used in the evaluation of ankle fractures. Development of complications and older age are associated with poor clinical outcomes.

Treating AO/OTA 44B lateral malleolar fracture in patients over 50 years of age: periarticular locking plate versus non-locking plate

Background

The role of locking plate in lateral malleolar fracture fixation for the elderly remains unclear. The aim of our study is to compare radiological and functional outcomes in older patients (> 50 years) with AO/OTA 44B lateral malleolar fractures after locking plate (PLP) or one-third non-locking tubular plate (TP) lateral fixation.

Methods

We retrospectively reviewed the medical records of 72 patients (PLP group, 34 patients; TP group, 38 patients; mean age, 61.9 ± 7.6 years; range, 51–80 years; follow-up, 1 year). Patients with open fractures, syndesmosis injuries, and a previous ankle trauma or surgery were excluded. Demographic data, union rate, complications, radiographic outcomes, visual analog scale (VAS) scores, and foot and ankle outcome scores (FAOSs) between the groups were recorded and compared. We also investigated the association of clinical features with pain and function. Statistically, the Fisher’s exact test was used for categorical variables and the Mann-Whitney U test for the continuous variables. The final model for the multiple regression analysis was used to predict factors related to functional outcomes.

Results

There were no significant between-group differences in demographic data, complication rates, immediately postoperative distal fibula lengths, ankle osteoarthritis (OA) grades, talar tilt angles (TTAs) ≥ 2°, or reduction accuracy. All fractures achieved union. The PLP group had significantly lower rates of distal screw loosening, fibula shortening > 2 mm, OA grade progression, and TTAs ≥ 2°, and better FAOSs and VAS scores than was the case for the TP group after 1 year of follow-up (all p < 0.05). The severity of OA, TTA ≥ 2°, and distal screw loosening were positively associated with VAS scores, and negatively associated with FAOSs.

Conclusions

When treating AO/OTA 44B fractures in patients over 50 years of age, PLPs provided better VAS scores, FAOSs, and radiological outcomes, including less fibula shortening > 2 mm, less osteoarthritic (OA) ankle progression, less implant removal rate, and fewer TTAs ≥ 2° than was the case for TPs after a 1-year follow-up.

Level of evidence

Therapeutic level III

Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases

Ankle fractures are common injuries frequently treated by foot and ankle surgeons. Therefore, it has become a core competency for orthopedic residency training. Surgical educators must balance the task of training residents with optimizing patient outcomes and minimizing morbidity and mortality. The present study aimed to determine the effect of resident involvement on the 30-day postoperative complication rates after open reduction and internal fixation of ankle fractures. A second objective of the present study was to determine the independent risk factors for complications after this procedure. We identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who had undergone open reduction internal fixation for ankle fractures from 2005 to 2012. Propensity score matching was used to help account for a potential selection bias. We performed univariate and multivariate analyses to identify the independent risk factors associated with short-term postoperative complications. A total of 3251 open reduction internal fixation procedures for ankle fractures were identified, of which 959 (29.4%) had resident involvement. Univariate (2.82% versus 4.54%; p = .024) and multivariate (odds ratio 0.71; p = .75) analyses demonstrated that resident involvement did not increase short-term complication rates. The independent risk factors for complications after open reduction internal fixation of ankle fractures included insulin-dependent diabetes, increasing age, higher American Society of Anesthesiologists score, and longer operative times.

Editorial Commentary: Limited Data Shows How Little We Know

Lateral compartment osteoarthritis of the knee can be a challenging problem to address in the younger, active population. The challenge is compounded by limited treatment options and high patient expectations, with patients often desiring a return to impact high intensity activity. Distal femoral osteotomy has been reported to be one potential treatment option; however, a highly heterogeneous literature exists for both opening and closing wedge distal femoral osteotomies for the treatment of isolated lateral compartment osteoarthritis with valgus malalignment. The literature does not provide significant direction for surgeons on the appropriate surgical approach; however, opening wedge osteotomies allow for fine adjustment and maintain leg length and joint alignment, and are our preferred approach.

Temporary transarticular K-wire fixation of critical ankle injuries at risk: a neglected "damage control" strategy?

High-energy ankle fracture-dislocations are at significant risk for postoperative complications. Closed reduction and temporary percutaneous transarticular K-wire fixation was first described more than 50 years ago. This simple and effective "damage control" strategy is widely practiced in Europe, yet appears largely forgotten and abandoned in the United States. Anecdotal opposing arguments include the notion that drilling K-wires through articular cartilage may damage the joint and contribute to postinjury arthritis. This article describes the experience in a US academic level I trauma center with transarticular pinning of selected critical ankle fracture-dislocations followed by delayed definitive fracture fixation once the soft tissues are healed. Median patient follow-up of 2 years showed that the transarticular pinning technique was performed safely, not associated with increased postoperative complication rates, and characterized by good subjective outcomes using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcome Score questionnaire.