Intramedullary Nail Fixation for the Treatment of Symptomatic Fibular Nonunion: A Case Series

Ankle fractures are a relatively common injury in the lower extremity. They can be treated with conservative management if they are nondisplaced and only involve the fibula. Nonunions at the fracture site, however, are a potential complicating factor during treatment. There is growing literature supporting the use of intramedullary fixation for fracture care. Not only does it have the advantages of using smaller incisions to preserve periosteum while providing improved biomechanical outcomes, but intramedullary reaming can help stimulate cells to promote bone healing. Few articles discuss the use and success of intramedullary reaming in revision surgery of the distal fibula. We present 3 cases of computed tomography-confirmed fibular nonunion following conservative fracture care, which underwent revision surgery with fibular nail fixation technique. These cases illustrate clinical and image findings as well as highlight the surgical technique used for each patient. At follow-up, all patients were asymptomatic and radiographs confirmed healing of the previous nonunion site. These cases are examples of successful revision for fibular fracture nonunion using intramedullary nail fixation.Level of Evidence: Level IV: Case series.

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.

[Progress in diagnosis and treatment of fibular fracture in ankle fracture]

OBJECTIVE

To summarize the diagnosis and treatment of fibular fracture in ankle fracture.

METHODS

Relevant literature at home and abroad in recent years was widely consulted, and various types of fractures were discussed and summarized according to Danis-Weber classification.

RESULTS

Conservative treatment is not an ideal treatment for type A avulsion fracture. The operation method should be determined according to the position and size of bone mass. For simple type B fracture, both conservative treatment and surgical treatment can achieve good results. When the position of type C fracture is high and does not affect the stability of ankle joint, it can be treated conservatively, while when the position is low and affects the stability of ankle joint, it needs surgical treatment.

CONCLUSION

First of all, whether the fibular fracture in the ankle fracture is stable or not should be determined. Whether it is treated surgically or not, the purpose is to restore the tibiofibular syndesmosis and restore the motor function of the ankle.

Compartment Syndrome Secondary to Knee Lipohemarthrosis

When treating patients presenting with knee trauma or intra-articular fracture, clinicians should maintain a high index of suspicion for lipohemarthrosis. Diagnosis of lipohemarthrosis can be accomplished via visualization of a fat-fluid level. Increased fluid and pressure build-up within the joint space may lead to compartment syndrome, which requires emergency compartment fasciotomy. In this paper, we discuss the importance of identifying lipohemarthrosis in patients presenting with intra-articular fracture, as well as the necessity of frequent patient re-evaluations in order to monitor the onset of compartment syndrome.

Concomitant Distal Tibia-Fibula Fractures Treated with Intramedullary Nailing, With or Without Fibular Fixation: A Meta-Analysis

There is no consensus on whether a fibular fracture should be fixed when a concurrent extra-articular distal tibia fracture is managed with intramedullary nails. We evaluated the use of fibular fixation in a meta-analysis of randomized trials and observational studies. Two researchers independently assessed the quality of eligible studies and extracted the data. We analyzed 4 trials with a pooled sample of 283 patients (mean age, 24 to 43 years; 141 men), 94 who had undergone fibular fixation and 189 who had not. Two randomized trials assessed on the Cochrane risk-assessment criteria were determined to have a moderate risk of bias, and 2 retrospective cohort studies evaluated with the Newcastle-Ottawa Scale were considered to be high quality. Tibia malalignment at follow-up times ranging from 12 to 72 weeks was reported in 20% (19/94) of patients in the fibular-fixation group and 67% (126/189) of patients in the nonfixation group, indicating that fibular fixation was significantly associated with a lower risk of malalignment (risk ratio, 0.34; 95% confidence interval [CI] 0.13 to 0.92; p = .03). The groups did not differ in the proportion of patients with malalignment immediately after surgery, delayed union, nonunion, or infection. When distal extra-articular tibia-fibular fractures are treated with intramedullary nails, fibular fixation may decrease the risk of late malalignment. Further randomized controlled trials with higher quality are required to verify the result.

A Modified 2-Stage Treatment for AO/OTA 43-C1 Pilon Fractures Accompanied by Distal Fibular and Posterior Lip of the Distal Tibia Fracture

The management of pilon fractures remains challenging owing to the high-energy axial loading mechanism that produces comminution of the articular surface, displacement of tibia metaphysis, and severe soft tissue injury. How to preserve the vitality of soft tissue and achieve anatomic reduction has become a timely issue. We report and evaluate the effect of a modified staging treatment for AO Foundation/Orthopaedic Trauma Association (AO/OTA) 43C1 pilon fracture accompanied by distal fibular and posterior lip of the distal tibia fracture. We performed a modified 2-stage treatment of type C1 pilon fracture with distal fibular and posterior malleolar fractures. In the first stage, the posterolateral incision was used for simultaneous reduction of fibula and posterior malleolus, and the tibia was fixed with an external fixator. In the second stage, the external fixator was removed, and the medial malleolus and tibia were fixed after the edema of soft tissue had subsided. The following data were collected: Foot and Ankle Outcome Score (FAOS), American Orthopaedic Foot & Ankle Society (AOFAS) score, Short Form 36 (SF-36) score, Burwell-Charnley fracture reduction score, and postoperative complications. Twenty-seven patients were monitored for an average of 31.70 ± 7.38 months. The Burwell-Charnley fracture reduction scores had anatomic and fair ratings of 92.59%. SF-36 physical component score was 42.94 ± 12.47 and mental component score was 48.73 ± 9.79. Score data from the multiple scales of FAOS included pain, 88.79 ± 8.59; activities of daily living, 91.89 ± 7.50; quality of life, 90.26 ± 10.52; sports, 87.93 ± 11.64; and symptoms, 85.32 ± 8.65. The AOFAS ankle-hindfoot scores were 87.30 ± 13.45. Complications were reported in 5 patients (18.52%). Our study provides a good alternative to the existing protocol for type C1 pilon fractures with distal fibular and posterior lip of the distal tibia fracture and effectively reduces soft tissue complications.

Plate fixation versus percutaneous rush pinning for osteosynthesis of the fibula in pilon fractures. A retrospective comparative study

BACKGROUND

Pilon fractures are complex injuries of the ankle associated with many postoperative complications. The optimal treatment for pilon fractures has not yet been established. This study aimed to determine the efficacy and compare the results of percutaneous rush pinning of the associated fibular fracture to the conventional open reduction and internal fixation.

METHODS

We included in the study all patients admitted in our department with the diagnosis of pilon fracture and associated fracture of the distal fibula and treated with primary open reduction and internal fixation between 2012 and 2018. We excluded patients treated with a two-stage approach, and those with an open fracture or neurovascular insufficiency.

RESULTS

The study included 87 patients; 45 had their distal fibular fracture operatively fixed with a one-third tubular plate (ORIF group), and the remaining 42 patients underwent percutaneous intramedullary pinning of the fibula fracture with a rush nail (Rush group). There were no statistically significant differences between the groups regarding age, gender, mechanism of injury, operating, and hospitalization time. The superficial infection rate was lower in the Rush group (p =0.039), but there were no statistically significant differences in the deep tissue infection, nonunion, and malunion incidence between the groups.

CONCLUSION

Percutaneous intramedullary rush pinning of the concomitant fibular fracture is a safe and reliable alternative treatment option in managing pilon fractures that could reduce the incidence of postoperative wound complications HIPPOKRATIA 2021, 25 (2):63-68.

A Specialized Fibular Locking Plate for Lateral Malleolar Fractures

We evaluated the outcomes and complications of a specialized fibular locking plate in the treatment of lateral malleolar fractures. The study included 27 patients (13 males and 14 females; mean age 46, range 16 to 73 years) with a minimum 1-year follow-up period. The study included 9 (33%) isolated lateral malleolar, 6 (23%) bimalleolar, 10 (37%) trimalleolar fractures, and 2 (7%) pilon fractures, all of which were treated using a specialized fibular locking plate for internal fixation. Bony union was monitored, and the patients' objective satisfaction was evaluated using the EQ-5D questionnaire (EuroQol Group). The patients were followed up after 1 year, and bony union was confirmed using a simple radiograph. The EQ-5D median ± standard deviation was 70 ± 15 (range 40 to 90) points at discharge, 80 ± 13 (range 40 to 90) at 6 weeks, 85 ± 11 (range 50 to 90) at 3 months, 90 ± 8 (range 60 to 90) at 6 months, and 90 ± 9 (range 70 to 95) at 1 year. Therefore, the EQ-5D score increased with time. No significant difference was found when stratified by sex or age (Mann-Whitney U test, p < .05). Eight complications (29%) developed: 1 superficial infection at the operative site, 1 case (3%) of osteomyelitis, 2 cases (7%) of an osteochondral lesion of the talus, and 5 cases (19%) of metallosis. A specialized fibular locking plate has the advantages of being an easy procedure, providing good patient satisfaction, and achieving complete bony union in all patients. However, additional complications developed compared with other well-known methods for fibular fracture treatment.