Fibula fractures management

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.

[Translated article] Fractures of the peroneal malleolus: Current concepts

Ankle fractures represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral malleolus are the most common, representing 65-70% of all cases. The therapeutic decision-making primarily relies on the stability of the ankle ring, considering it stable if affected at one point and unstable if two or more points are affected. Surgical treatment focuses on restoring the length of the fibula, joint reconstruction, stabilising the syndesmosis, and providing a stable fixation. It is crucial to rule out associated injuries that may influence therapeutic management. This article reviews the evaluation and management of lateral malleolus fractures, proposes a decision-making algorithm, and examines several fibular fixation options.

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.

Fractures of the peroneal malleolus: Current concepts

Ankle fractures represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral malleolus are the most common, representing 65-70% of all cases. The therapeutic decision-making primarily relies on the stability of the ankle ring, considering it stable if affected at one point and unstable if two or more points are affected. Surgical treatment focuses on restoring the length of the fibula, joint reconstruction, stabilizing the syndesmosis, and providing a stable fixation. It is crucial to rule out associated injuries that may influence therapeutic management. This article reviews the evaluation and management of lateral malleolus fractures, proposes a decision-making algorithm, and examines several fibular fixation options.

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.

Residual Medial Ankle Pain After the Delayed Union of a Lateral Malleolus Fracture: A Case Report

A 17-year-old girl sprained her left ankle and was diagnosed with a lateral malleolar fracture. She was treated conservatively for six months but had medial ankle pain with activity. Imaging revealed an oblique lateral malleolar fracture, with posterolateral displacement and partial fusion of the bone fragments, and bone marrow edema on the medial articular surface of the talus and medial malleolus. We diagnosed ankle instability due to delayed union with a displacement of the lateral malleolus, which caused an osteochondral lesion. We performed arthroscopic and open surgery eight months after the injury, reducted the lateral malleolus anatomically, and fixed it with a plate. Postoperatively, the pain improved rapidly, and the bone marrow edema had almost disappeared on an MRI. In this case, we think rotational instability of the ankle mortise caused abnormal pressure and continuous stress on the medial malleolus after injury, which may have contributed to persistent medial ankle pain.

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.

Disparity in sex in ankle fracture treatment

BACKGROUND

Literature has shown implicit bias in the treatment between non-operative and surgical treatment in patients with certain types of ankle fractures, which comprise 7.6% of all adult fractures. An understanding of any bias across all ankle fracture management may prove to be critical for the understanding of potential correlations between treatment methods and outcomes of patients with ankle fractures. Therefore, this study aimed to determine whether there is a sex-based bias in the operative and non-operative treatment of all ankle fractures.

METHODS

A retrospective study of 1175 adult patients with ankle fractures was conducted. Data extracted included sex, race, age, type of treatment (non-operative/operative), fracture type (displaced/non-displaced), fracture class, BMI, and length of hospital stay. Odds ratio (OR), Chi-squared, t-test, and Pearson's correlation tests were used with p < 0.05 considered significant.

RESULTS

The study population consisted of 750 females (63.8%) and 425 males (36.2%). The study demonstrated a sex-based disparity in operative and non-operative treatment revealing that women are less likely than men to receive operative treatment for displaced ankle fractures (OR = 0.7, 95% CI: 0.5-0.9, p = 0.01). Of the 750 females, 417 (55.6%) underwent non-operative treatment, while 333 (44.4%) females had an operation. Of the 425 males, 204 (48%) had non-operative treatment, while 221 (52%) underwent operative treatment. The distribution of ankle fracture classes between both sexes was similar, suggesting fracture class did not influence the observed disparity.

CONCLUSION

Our results suggest sex correlates with the treatment type for ankle fractures, with women more likely to receive non-operative treatment for displaced fractures. As post-treatment outcomes often reflect the chosen form of treatment, it is imperative to determine if a disparity in sex explicates differences in clinical outcomes.

Influence of Patient-Reported Outcome Measures by Surgical Versus Conservative Management in Adult Ankle Fractures: A Systematic Review and Meta-Analysis

Background and Objective: This meta-analysis was performed to compare the effectiveness of surgical treatment and conservative treatment in adult ankle fractures. Methods: Pubmed, Embase, and Cochrane-Library databases were searched to retrieve prospective randomized-controlled studies that compared the efficacy of surgical treatment and conservative treatment in adult ankle fractures. The meta package in R language was used to organize and analyze the obtained data. Results: A total of eight studies involving 2081 patients was considered eligible, including 1029 patients receiving surgical treatment and 1052 receiving conservative treatment. This systematic review and meta-analysis was prospectively registered on PROSPERO, and the registration number is CRD42018520164. Olerud and Molander ankle-fracture scores (OMAS) and the health survey 12-item Short-Form (SF-12) were used as main outcome indicators, and the follow-up outcomes were grouped according to the follow-up time. Meta-analysis results showed significantly higher OMAS scores in patients receiving surgical treatment than those with conservative treatment at six months (MD = 1.50, 95% CI: 1.07; 1.93) and over 24 months (MD = 3.10, 95% CI: 2.46; 3.74), while this statistical significance was absent at 12-24 months (MD = 0.08, 95% CI: -5.80; 5.96). At six months and 12 months after treatment, patients receiving surgical treatment exhibited significantly higher SF12-physical results than those receiving conservative treatment (MD = 2.40, 95% CI: 1.89; 2.91). The MD of SF12-mental data at six months after meta-analysis was -0.81 (95% CI: -1.22; 0.39), and the MD of SF12-mental data at 12+ months was -0.81 (95% CI: -1.22; 0.39). There was no significant difference in SF12-mental results between the two treatment methods after six months, but after 12 months, the SF12-mental results of patients receiving surgical treatment were significantly lower than those of conservative treatment. Conclusions: In the treatment of adult ankle fractures, surgical treatment is more efficacious than conservative treatment in improving early and long-term joint function and physical health of patients, but it is associated with long-term adverse mental health.

The statistical fragility of the distal fibula fracture literature: A systematic review of randomized controlled trials

BACKGROUND

The purpose of this study was to apply both the fragility index (FI) and fragility quotient (FQ) to evaluate the degree of statistical fragility in the distal fibular fracture (DFF) literature. We hypothesized that the dichotomous outcomes within the DFF literature are statistically fragile.

METHODS

We performed a PubMed search for distal fibular fractures clinical trials from 2000 to 2022 reporting dichotomous outcomes. The FI of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The FQ was calculated by dividing each fragility index by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ.

RESULTS

Of the 1158 articles screened, 23 met the search criteria, with six RCTs included for analysis. Forty-five outcome events with 5 significant (p < 0.05) outcomes and 40 nonsignificant (p ≥ 0.05) outcomes were identified. The overall FI and FQ was 5 (IQR 4-6) and 0.089 (IQR 0.061-0.107), respectively.

CONCLUSIONS

The randomized controlled trials in the peer-reviewed distal fibular fracture literature may not be as robust as previously thought, as incorporating statistical analyses solely on a P value threshold is misleading. Standardized reporting of the P value, FI and FQ can help the clinician reliably draw conclusions based on the fragility of outcome measures.

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.