Fibula Fracture: Plate versus Nail Fixation

Open reduction and internal fixation compared to intramedullary nail fixation in distal fibula fractures: a meta-analysis

The operative treatment of distal fibula fractures is debated. This study compared intramedullary nailing (IMN) versus open reduction and internal fixation (ORIF) in patients with distal fibula fractures. The outcomes of interest were patient-reported outcome measures (PROMs) and the rate of anatomic reduction, bony union, complication, and nerve injury. This study was conducted according to the 2020 PRISMA statement. In October 2024, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase, with no time constraint. All the clinical studies comparing IMN versus ORIF in patients with distal fibula fractures were accessed. Data from 11 studies (1040 patients) were retrieved. The mean length of follow-up was 25.1 ± 16.4 months. The mean age of the patients was 56.6 ± 14.8 years, and the mean BMI was 27.3 ± 1.3 kg/m2. A lower rate of nerve injury was evident in favour of the IMN group (P = 0.01). No further differences were found in the Olerud-Molander functional score (P = 0.07), the rate of anatomic reduction (P = 0.4), union (P = 0.9), and complications (P = 0.1). Concluding, osteosynthesis using ORIF might be associated with a greater nerve injury rate than IMN fixation in patients with distal fibula fractures; however, additional studies are required to establish the rate and type of nerve lesion. No difference was found in PROMs, rate of anatomic reduction, bony union, and other complications.

Comparison of the outcomes of syndesmotic ankle fractures treated with dynamic fixation versus static fixation versus fibular nail: a meta-analysis and systematic review

Background

Syndesmotic ankle fractures occur when there is damage to the syndesmosis complex, resulting in severe pain and instability. Treatment methods include static fixation, dynamic fixation, and fibular nailing. This systematic review and meta-analysis aims to compare the outcomes of these surgical interventions for syndesmotic ankle fractures.

Methods

PubMed and Embase were searched up until April 2024 for comparison studies that included at least two of the treatment methods and relevant functional outcomes and complication metrics. Review Manager 5.4 was used for statistical analyses, and a P value ≤0.05 was considered statistically significant. Risk of bias was assessed with Review Manager 5.4. and the Newcastle-Ottawa scale.

Results

Nineteen studies with a total of 1,182 patients met the inclusion criteria. Compared to static fixation, dynamic fixation had a significantly higher Olerud-Molander Ankle Score (OMAS) at both 1-year [standardized mean difference (SMD) =0.43; 95% confidence interval (CI): 0.22 to 0.65; P<0.05] and 2-year post-operation (SMD =0.76; 95% CI: 0.33 to 1.20; P<0.05). Dynamic fixation had a significantly lower reoperation rate than static fixation [risk ratio (RR) =0.55; 95% CI: 0.36 to 0.83; P=0.004]. Compared to static fixation, fibular nail had a significantly higher OMAS at 1-year post-operation (SMD =0.28; 95% CI: 0.03 to 0.53; P=0.03). Fibular nails had significantly lower infection (RR =0.12; 95% CI: 0.04 to 0.37; P<0.05) and reoperation rates (RR =0.22; 95% CI: 0.06 to 0.86; P=0.03) than static fixation. Compared to fibular nail, dynamic fixation had a significantly higher OMAS at both 1-year (SMD =1.07; 95% CI: 0.83 to 1.31; P<0.05) and 2-year post-operation (SMD =1.03; 95% CI: 0.60 to 1.47; P<0.05). Dynamic fixation had a significantly higher reoperation rate compared to fibular nail (RR =20.41; 95% CI: 2.81 to 148.21; P=0.003).

Conclusions

Dynamic fixation seems to be the superior treatment method, displaying better outcomes than static fixation and fibular nailing, with the fibular nail proving to be a viable alternative. Dynamic fixation should be the first choice of treatment for those with syndesmotic ankle fractures due to its clinical advantages compared to static fixation and fibular nailing.

Level of Evidence

3.

The fibular intramedullary nail versus plate fixation for ankle fractures in adults: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The effectiveness and safety of fibular intramedullary nail fixation (FINF) compared to plate fixation (PF) in treating ankle fractures among adults remains unclear. Therefore, we conducted a meta-analysis to assess the efficacy and safety of FINF versus PF, aiming to provide orthopedic surgeons with valuable insights when choosing between the two internal fixation methods for patient treatment.

METHODS

PubMed, EMBASE, and SCOPUS were systematically searched for articles comparing FINF and PF in ankle fractures among adults. Functional outcomes, complications, and bony union were compared between the implants.

RESULTS

A total of seven studies were included in the study, involving 586 patients. The results revealed no statistically significant differences in functional outcomes between two groups at 3, 6, and 12 months postoperatively. The outcomes favoring FINF comprised a lower infection rate (RR = 0.23, 95%CI, 0.11 to 0.47, P < 0.0001). Conversely, the PF group exhibited a superior performance in terms of hardware failure rate (RR = 2.05, 95%CI, 1.16 to 3.60, P = 0.01). A statistically significant difference was observed in the results of hardware failure rate in the subgroup of studies conducted in Europe (RR = 2.74, 95%CI, 1.45 to 5.18, P = 0.002). Comparable findings were also noted in a subgroup of older adults (RR = 4.25, 95%CI, 1.57 to 11.50, P = 0.004).

CONCLUSION

This systematic review suggests that FINF exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to PF. Consequently, it is imperative to further delineate the surgical indications for both FINF and PF with precision to mitigate the risk of complications. Nevertheless, larger sample sizes and multi-center RCTs are imperative to corroborate this conclusion in the future.

Evaluating Fibular Intramedullary Nails vs Traditional Plating in Geriatric Ankle Fractures: A 12-Year Single-Center Retrospective Study

BACKGROUND

This study evaluates the outcomes of fibular intramedullary nails (IMNs) compared to traditional plates and screws (PS) in the surgical treatment of unstable ankle injuries in patients aged ≥65 years.

METHOD

We conducted a retrospective study involving 32 elderly patients with unstable ankle fractures treated with IMNs from 2010 to 2022. A comparison was made with 125 case-control patients treated with PS during the same period. Outcomes compared included postoperative wound and nonwound complications, surgical reduction, union rates, implant removal rates, and the Olerud Molander Ankle Score (OMAS) at a minimum follow-up of 2 years.

RESULTS

The IMN group had a higher incidence of high-energy injuries, open fractures, concomitant surgery, and perioperative transfusion requirements than the PS group. Additionally, the IMN group developed fewer wound-related (3.1% vs 20% in the PS group, P = .043) and non-wound-related complications (18.8% vs 39.2% in the PS group, P = .030). Both groups had similar initial weightbearing restrictions, fracture union times, mean OMAS scores, rates of malunion or nonunion, and delayed implant removal times. Notably, there were significant differences in the quality and adequacy of mortise alignment between the groups (good: 53.1% in IMN group vs 79.2% in PS group, fair: 46.9% in IMN group vs 20.8% in PS group, P = .006).

CONCLUSION

Although the IMN group had an inferior outcome in the quality and adequacy of mortise reduction compared with the PS group, elderly patients with ankle fractures treated with IMN showed comparable functional outcomes to those treated with PS but with lower complication rates. Future research in this area will provide vital information for developing optimal treatment strategies, thereby improving the overall care of elderly patients with ankle fractures.

Current Trends in the Surgical Treatment of Fibular Fractures: A National Database Study of Intramedullary vs. Plate Fixation Practice Patterns, Complications, and Cost

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.

Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review

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.

Intramedullary Nailing Versus Open Reduction and Plate Fixation for Lateral Malleolar Fractures: A Meta-Analysis

The fixation for lateral malleolar fracture in ankle fractures is still controversial. The purpose of this meta-analysis is to compare clinical and radiological outcomes between intramedullary nail (IMN) and plate for lateral malleolar fractures in ankle fractures. The PubMed, EMBASE, and Cochrane Library were searched for randomized controlled trials (RCTs) from databases inception to June 2023. Data on outcomes were extracted and the methodological quality of the included studies were assessed. A meta-analysis was performed using RevMan 5.3 software when the data extracted from included studies could be synthesized. Seven RCTs were included. The methodological quality of the included studies was moderate to high. The meta-analysis results showed that the infection rate of the IMN group was significantly lower than that of the plate group (RR = 0.38; 95%CI 0.18-0.82; p = .01). There were no significant differences between the 2 groups in Olerud and Molander Ankle Score (OMAS), union rate, radiological outcomes, nerve injury rate, reoperation rate, loss of reduction, and total complication rate. Our present meta-analysis demonstrated that the IMN might be a better method for the fixation of lateral malleolar fracture in ankle fracture, as the infection rate was significantly lower than a plate.

Comparative Analysis of Intramedullary Nail versus Plate Fixation for Fibula Fracture in Supination External Rotation Type IV Ankle Injury

BACKGROUND Lateral malleolus fractures, typically from trauma, sports, or accidents, are common, with supination external rotation (SER) injuries being most prevalent. SER injuries involve complex joint mechanics and often necessitate surgical intervention for instability. This study compares intramedullary nail and plate fixation for fibula fractures in SER type IV ankle injuries, considering their biomechanical properties and influence on fracture healing. MATERIAL AND METHODS A prospective, randomized study was conducted between January 2021 and December 2021. A total of 81 patients with SER injuries were included in the study. Surgical procedures were performed using either intramedullary nails or plates. The following parameters were recorded and analyzed: postoperative complications, operation times, bone healing times, American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores for pain, and ankle range of motion. RESULTS Out of the 81 cases, 42 were treated with intramedullary nails, while 39 received plate fixation. Statistical analysis revealed a significantly lower rate of postoperative complications in the intramedullary nail group than in the the plate fixation group (9.52% vs 30.77%, P<0.0164). However, there were no significant differences between the 2 groups in terms of operation time, bone healing time, AOFAS scores, VAS scores, and functional evaluations (P>0.05). CONCLUSIONS Plate fixation and intramedullary nail fixation are effective techniques for treating fibula fractures in SER type IV injuries. However, intramedullary nail fixation demonstrates a lower rate of complications. Therefore, intramedullary nails may be preferable to plate fixation for the management of fibula fractures in SER type IV ankle injuries.

Use of Fibula Nails With Proximal and Distal Fixation

Background

Ankle fractures are a frequent injury in the adult population and a quarter of all ankle fractures are classified as unstable, requiring surgical intervention. Plate-and-screw construct is the traditionally used fixation method for fibula fractures. The use of an intramedullary nail is an alternative fixation method, with current literature supporting very low complication rates and hardware removal surgeries. The purpose of this study was to evaluate the outcomes, including complication rates and implant removal rates, using a fibula nail with both proximal and distal fixation capabilities by an experienced surgeon.

Methods

We retrospectively reviewed 203 consecutive fibula nail cases from a single surgeon using a mini-open technique for anatomic reduction. Demographic, operative, clinical, and radiographic outcome data were analyzed, specifically examining complication rates and need for implant removal.

Results

The average follow-up was 18.8 months (6-54 months). All fractures healed. We identified 2 cases of superficial wound infection, 1 superficial peroneal nerve irritation, and 1 case of implant removal. In the first 110 cases, 2 fractures were converted to a plate intraoperatively prior to a technique modification which has prevented this occurrence. No deep infection, delayed union, or nonunion occurred.

Conclusion

Our data support that fibula nails with proximal and distal locking capabilities offer an alternative to plating with the potential for lower complication rates and lower need for implant removal.

Level of evidence

Level IV, case series.

Results of prophylactic simple fasciocutaneous advancement in the initial management of acute ankle fractures with high risk of operative wound complication

Ankle fracture is the third most prevalent fracture in older adults. Wound dehiscence is the most frequent complication. Our objective is to determine the operative wound complication rate in patients with unstable ankle fracture in whom a prophylactic simple fasciocutaneous advancement was used.

METHODS

Prospective registry of patients with unstable ankle fracture, in whom a prophylactic fasciocutaneous advancement was performed between August 2020 and July 2021. Demographic variables, time spent in performing the flap, cost of osteosynthesis, minor and major complications of the surgical wound, readmission or reoperation were registered.

RESULTS

42 older adults with ankle fracture were included. Median age 69 (60-94). 31% diabetics and 21.5% active smokers. A 40% trimalleolar fracture pattern. There were 7% of superficial complications of the surgical wound. No major complications, no reoperations.

CONCLUSIONS

Prophylactic fasciocutaneous advancement at the beginning of traumatological surgery is technically simple, reproducible, cheap and with low complications.

LEVEL OF EVIDENCE

Level IV, cross-sectional study.

A Retrospective Analysis of Distal Fibula Fractures Treated With Intramedullary Fibular Nail Fixation

There is growing literature supporting the use of intramedullary fixation for fracture care because of its smaller incisions, improved biomechanical outcomes, and faster time to weightbearing than traditional internal fixation methods. The aim of this study is to investigate the postoperative outcomes in ankle fractures treated with intramedullary nail fixation in the largest patient cohort to date. From 2015 to 2021, 151 patients were evaluated following surgical treatment of fibular fractures with intramedullary nail fixation. Patients were identified through a medical record database search for appropriate ankle fracture procedure codes. Patient information was reviewed for fracture type, adjunct procedures, time to weightbearing and postoperative complications. Radiographs were assessed for quality and time to radiographic union. The mean time to weightbearing was 4.8 weeks. Minor wound dehiscence was identified in 2 patients (1.3%). Superficial infection was present in 4 patients (2.6%) and a deep infection developed in 2 patients (1.3%). Two patients developed a nonunion (1.5%). There were no DVTs reported, although 1 patient developed a PE postoperatively. Radiographic quality of reduction and time to union is comparable to literature reported plate and screw construct outcomes. Reduction was classified as good in 86.1% of patients and radiographic union was appreciated in 98.5% of patients. This is the largest cohort study evaluating the outcomes of intramedullary nail fixation for ORIF of ankle fractures. These data reinforce that intramedullary nailing provides a minimally invasive approach with accurate anatomic reduction, excellent fracture union rates, low complication rates, and an early return to weightbearing.

Can Locked Fibula Nail Replace Plate Fixation for Treatment of Acute Ankle Fracture? A Systematic Review and Meta-Analysis

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.

Restoration of Anatomic Parameters and Syndesmotic Reduction After Intramedullary Nailing of Distal Fibular Fractures

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.

Comparing bilateral feet computed tomography scans can improve surgical decision making for subtle Lisfranc injury

INTRODUCTION

Subtle Lisfranc injuries (SLIs) are challenging to diagnose. Although weightbearing (WB) radiographs have been suggested to identify SLIs, approximately 20% are missed on initial radiographic assessment. Computed tomography (CT) has been suggested as an alternative, but has not provided any diagnostic guideline. Therefore we compared measurement techniques on radiographs and bilateral foot CT scans for the efficiency of diagnosis and making surgical decisions for SLI.

METHODS

We retrospectively investigated patients diagnosed with SLIs between January 2014 and January 2020. Distances between both medial cuneiform and second metatarsal base (C1M2), and the first and second metatarsal bases (M1M2), were measured on bilateral WB radiographs. Bilateral foot CT scans were taken, and the distances between C1M2 were checked on the axial and three points of the coronal plane (top, middle, and base). The surgical indication was > 1 mm of diastasis on CT scan. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score at final follow-up. Intraobserver and interobserver agreements were assessed.

RESULTS

Thirty patients with SLIs were reviewed. Twenty-four patients underwent surgical fixation (Group A) and six patients were treated conservatively (Group B). The side-to-side difference (STSD) of C1M2 and M1M2 distances greater than 1 mm showed 91.7% and 54.2% sensitivity, and 66.7% and 16.7% specificity, respectively. Investigating STSDs of all points on CT scans were informative to discriminate both groups (P ≤ 0.038). Clinical outcomes showed no significant difference between the groups (P = 0.631). Intraclass and interclass correlation coefficient values showed good to very good reliability, except for STSD of WB M1M2 distance and the coronal top plane.

CONCLUSION

Investigating bilateral foot CT scans was significantly efficient and reliable for the diagnosis and treatment plan for SLI. On radiographs, STSD of WB C1M2 distance was more sensitive than STSD of WB M1M2 distance.

LEVEL OF EVIDENCE

Case control study; III.

Comparison between headless compression screws and tension band wires for the fixation of medial malleolar fractures: a prospective randomized trial

INTRODUCTION

To date, there has been no prospective randomized trial supporting the rationale of the use of headless compression screw (HCS) compared to conventional fixation methods for medial malleolar fractures. This study aimed to prospectively compare the outcomes of the HCS and tension band wire (TBW) for the fixation of medial malleolar fractures.

MATERIAL AND METHODS

Sixty patients were randomized to receive either an HCS or a TBW for the fixation of a medial malleolar fracture. Clinical outcomes were assessed using the Olerud-Molander ankle score (OMAS), EuroQoL five-dimensional instrument (EQ-5D) score, visual analog scale (VAS) score, patient satisfaction with implant-related symptoms, operative time, and incision length. Radiographic outcomes were assessed using the presence of nonunion, delayed union, and articular incongruity. Clinical and radiographic assessments were performed at 2 and 6 weeks and 3, 6, and 12 months postoperatively.

RESULTS

The OMAS, EQ-5D score, VAS score, and operative time did not differ between the HCS and TBW groups; however, the HCS group had greater satisfaction with implant-related symptoms and smaller incision than the TBW group. There was no difference in the presence of nonunion, delayed union, and articular incongruity.

CONCLUSION

HCS fixation for medial malleolar fractures is not inferior to TBW fixation, while reducing implant-related symptoms. These findings suggest that HCS is a viable alternative for the fixation of medial malleolar fractures.

Locked intramedullary nailing provides superior functional outcomes and lower complication rates than plate fixation of distal fibula fractures. A systematic review and meta-analysis of comparative studies

PURPOSE

This study aims to provide an updated systematic review and meta-analysis of comparative studies on the outcomes and complications of locked IMNs in comparison to ORIF using plates and screws, while avoiding limitations of similar published reviews.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout May 2021 using the following keywords with their synonyms: "Ankle fracture fixation" AND "Open reduction and internal fixation", "locked intramedullary nail", or "complications". The primary outcomes were (1) functional outcomes, (2) complications, and (3) reoperation, while the secondary outcomes were: (1) union rate, and (2) cost.

INCLUSION CRITERIA

comparative studies on outcomes and complications of plate open reduction and internal fixation (ORIF) vs. locked intramedullary nailing (IMN) of ankle fractures reporting at least one of the following parameters: functional outcomes, complications (infection, dehiscence, reoperation etc.), union, and cost. Studies reporting on non-locked intramedullary fibular nails were also excluded.

RESULTS

After the removal of duplicates, a total of 1461 studies were identified. After screening those records, 63 studies remained for full-text assessment. Out of those, four comparative studies with a total of 262 ankle fractures met the inclusion criteria for this meta-analysis. The mean 12 months postoperative Olerud and Molander Ankle Scores (OMAS) were reported by two studies, with a statistically significant difference in favor of IMNs (MD= 6.72, CI: 3.77-9.67, p<0.001, I²= 94%). In the ORIF group, the overall complication rate was 39/134 (29.1%) vs. 10/128 (7.8%) in the IMN group, with a statistically significant difference in favor of the IMN group (RR=3.23, CI:1.71-6.11, p<0.001, I²=34%). In the ORIF group, the overall infection rate was 11/134 (8.2%), while there were no infections in the IMN group, with a statistically significant difference in favor of the IMN group (RR=8.05, CI:1.51-42.82, p=0.01, I²=0%). In the ORIF group, the overall reoperation rate was 10/134 (7.5%) while the overall reoperation rate was 6/128 (4.7%) in the IMN group, with no statistically significant difference between groups (RR=1.49, CI: 0.60-3.70, p = 0.39, I²=0%).

CONCLUSION

Locked intramedullary nail fixation of distal fibula fractures could provide superior functional outcomes and lower complication rates in comparison to open reduction and plate fixation. Despite the high incidence of ankle fractures, the number of high-quality comparative studies remains limited in literature, especially on newer locked fibular nails, and large multicentric clinical trials are required before recommending locked IMNs as the new standard of care in distal fibula fractures.

Intra-articular Calcaneal Fracture Treatment With Staged Medial External Fixation

BACKGROUND

To compare the clinical and radiographic outcomes between the conventional delayed and staged approaches for intra-articular calcaneus fractures in which early definite fixation could not be performed because of severe soft tissue injury.

METHODS

From January 2015 to May 2019, a total of 32 cases with acute intra-articular calcaneal fractures met criteria and were enrolled in the study. We compared the outcomes of intra-articular calcaneal fractures that underwent delayed internal fixation between groups treated with a conventional delayed approach (non-EF group) vs a temporary medial external fixation (EF group). Clinical outcome measures included a 10-point visual analog scale score, the AOFAS score, and the Foot Function Index. Radiographic outcome measures included Böhler angle, talar declination angle, and calcaneal width. Reduction of the posterior facet was assessed on CT scans.

RESULTS

The first 15 (46.9%) were treated with a conventional delayed approach, and the latter 17 (53.1%) were treated with a staged approach with temporary medial external fixation. Clinical outcomes were not different between the groups at the last follow-up. The time from injury to definite internal fixation was shorter by an average of 3.8 days in the EF group (P = .001). The Böhler angle, talar declination angle, and calcaneal width were not different between the groups before surgery and at the last follow-up. Reduction of the posterior facet on CT scans was significantly better in the EF group than in the non-EF group (good/excellent = 94% vs 60%, respectively, P = .033).

CONCLUSION

The staged approach using medial external fixation for displaced intra-articular calcaneus fractures could be an effective method to decrease the time to definitive internal fixation and obtain optimal reduction of the posterior facet.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Fibula Nail Outcomes in Soft Tissue Compromised Ankle Fractures

BACKGROUND

To determine the clinical outcomes following fibula nail fixation and to identify the indication for the use of fibula nails in lower limb fractures.

METHODS

Retrospective study of adult patients from 2 major trauma centers (MTCs) and 9 trauma units (TUs) who underwent fibula nail fixation for AO/OTA 44 fractures between January 1, 2018, and October 31, 2020. Outcome measures included infection, metalwork complications, nonunion or malunion, time to union, and length of inpatient hospital stay.

RESULTS

Ninety-five patients were included, with a mean age of 66 years; 57.9% of patients were female. The average body mass index was 30. Sixty-nine patients (72.6%) sustained a Weber B and 24 (27.4%) sustained a Weber C fracture. In addition, 26.3% were open fractures and all patients had soft tissue compromise affecting the lateral malleolus. The calculated infection rate for fibula nail was 4.2% and metalwork complication rate was 5.2%. The nonunion and malunion rate was 8.4% and rate of removal of hardware was 2.1%. The average time to union was 12.5 weeks, and length of inpatient stay was 9.4 days (SD 10).

CONCLUSION

This multicenter study demonstrates that use of a fibula nail appears to be a safe approach to treating patients who have a physiologically higher risk of surgery, poor skin condition, and a complex fracture pattern.

LEVEL OF EVIDENCE

Level III, case-control study.

Intraoperative chertsey test, is it a reliable alternative to computed tomography scan for diagnosing syndesmotic injuries of the ankle?

Background:

The present study aims to evaluate the diagnostic exactitude of the intraoperative Chertsey test in tibiofibular syndesmotic injuries in patients with malleolar fractures, in comparison with a computed tomography (CT) scan.

Materials and Methods:

In this study, patients with malleolar fractures operated between 2018 and 2020 were examined. Thirty-nine patients were enrolled in the study. A three-dimensional preoperative CT scan was obtained. The opposite unfractured ankle was also scanned and considered as the control group. The Chertsey test was performed during the operation to assess the syndesmosis injury. Then, patients were partitioned into two distinct groups, considering the condition of their ankle, namely the Chertsey positive (unstable syndesmosis) group and the Chertsey negative (stable syndesmosis) group.

Results:

The outcomes of the present survey illustrated that the Chertsey test was positive in 16 patients (41.03%) and negative in 23 patients (59.07%). The median of all CT scan parameters (anterior tibiofibular distances (TFD), middle TFD, posterior TFD, and maximal TFD and volume) before surgery in the group of patients with a positive Chertsey test was significantly higher, measured against the unfractured control group (P < 0.001 for all parameters). Furthermore, a comparison of CT scan parameters and syndesmosis space volume before surgery between the two groups of patients with positive and negative Chertsey test results showed that the measurement of parameters in Chertsey-positive patients was significantly higher than the Chertsey-negative patients (P < 0.001).

Conclusion:

Chertsey test could be used to diagnose syndesmosis injuries in patients with malleolar fractures due to its high importance in the outcome of patients.

The Valid Diagnostic Parameters in Bilateral CT Scan to Predict Unstable Syndesmotic Injury with Ankle Fracture

The purpose of this study is to evaluate the reasonable parameters to predict unstable syndesmotic injuries in ankle fractures. Seventy consecutive patients who underwent preoperative bilateral computed tomography (CT) scans were enrolled. Group A consisted of 20 patients intraoperatively diagnosed with syndesmotic injuries according to an intraoperative stress test and group B consisted of 50 patients who had nosyndesmotic injuries. The tibiofibular overlap (TFO) and tibiofibular clear space (TFCS) were measured using preoperative ankle radiographs. Measuring the anterior fibular distance (AFD), posterior fibular distance (PFD), anterior translation distance (AT), fibular diastasis (FD), anterior-posterior translation (APT), fibular length (FL), and surface area of syndesmosis (SAS) 1.0 and 1.5 which 1.0 cm and 1.5 cm above the tibial plafond was done via preoperative CT scan. The ratio of measurements (Injured/Intact) of the TFO, PFD, APD, and SAS 1.0 showed statistically significant differences. The researchers identified the SAS 1.0 as the most reasonable parameter to predict transfixation using receiver-operating characteristic (ROC) curve analysis. The SAS 1.0 is most valid parameter to predict syndesmotic injuries in this study and these results show that performing a bilateral CT scan on an ankle fracture may provide substantial information in measuring valid parameters.