The Role of Fibular Fixation in Distal Tibia-Fibula Fractures: A Meta-Analysis

Objectives. The necessity of fibular fixation in distal tibia-fibula fractures remains controversial. This study aimed to assess its impact on radiographic outcomes as well as rates of nonunion and infection. Methods. A systematic search of the electronic databases of PubMed, Embase, and Cochrane library was performed to identify studies comparing the outcomes of reduction and internal fixation of the tibia with or without fibular fixation. Radiographic outcomes included malalignment and malrotation of the tibial shaft. Data regarding varus/valgus angulation, anterior/posterior angulation, internal/external rotation deformity, and the rates of nonunion and infection were extracted and then polled. A meta-analysis was performed using the random-effects model for heterogeneity. Results. Additional fibular fixation was statistically associated with a decreased rate of rotation deformity (OR = 0.13; 95% CI 0.02–0.82,p=0.03). However, there was no difference in the rate of malreduction between the trial group and the control group (OR = 0.86; 95% CI 0.27–2.74,p=0.80). There was also no difference in radiographic outcomes of varus-valgus deformity rate (OR = 0.17; 95% CI 0.03–1.00,p=0.05) or anterior-posterior deformity rate (OR = 0.76; 95% CI 0.02–36.91,p=0.89) between the two groups. Meanwhile, statistical analysis showed no significant difference in the nonunion rate (OR = 0.62; 95% CI 0.37–1.02,p=0.06) or the infection rate (OR = 0.81; 95% CI 0.18–3.67,p=0.78) between the two groups. Conclusions. Additional fibular fixation does not appear to reduce the rate of varus-valgus deformity, anterior-posterior deformity, or malreduction. Meanwhile, it does not appear to impair the union process or increase the odds of infection. However, additional fibular fixation was associated with decreased odds of rotation deformity compared to controls.

Intramedullary Fixation of Distal Fibula Fractures

Category: Trauma Introduction/Purpose: The current gold-standard for unstable distal fibula fractures is plate and screw fixation; however, intramedullary distal fibular fixation is becoming more commonplace. Although surgeons may consider this technique only for patients requiring extra soft tissue protection, recent studies are showing that it is a safe and effective technique for maintaining adequate reduction and promoting proper fracture healing in a wide-variety of ankle fractures. As newer techniques and equipment are developed, it is important to continue with analyzation of patient outcomes. Our study evaluates a intramedullary device that contains a unique proximal locking mechanism that deploys fins against the inner cortex to help maintain fracture length and control rotation. To our knowledge, no other study in the literature has evaluated this technique for distal fibula fractures. Methods: A retrospective case-series was conducted on all patients >18-years old with unstable ankle fractures treated with the same intramedullary distal fibular fixation, that contained the unique proximal locking system. Surgeries were performed at a single institution by a single surgeon between September 2015 and June 2018. Patient imaging was carefully assessed for quality of reduction using previously established guidelines classifying reductions as “good”, ”fair”, or “poor”. Patient charts were also assessed for comorbidities, initial fracture classification, postoperative complications, and need for additional surgery. Results: Forty-one patients were included in the study. Twenty-five patients were female and 16 patients were male. Average age was 52. Average follow-up was 10.0 months. Eleven fractures were bimalleolar (27%), eight were isolated distal fibula fractures (20%), eight were bimalleolar-equivalent fractures (20%), nine were trimalleolar fractures (22%), and five were pilon fractures (12%). Seventy-one percent were Weber B and 29% were Weber C. Based on the classification system, 37 fracture reductions (90%) were classified as ”good”, four were “fair” (10%), and no reductions were ”poor”. There were no instances of hardware failure, loss of reduction, or nonunion. One patient had a superficial wound infection, one patient had a deep wound infection, five patients require painful hardware removal, and one patient had a delayed union. Conclusion: This large case-series is the first study, to our knowledge, in the Foot and Ankle literature to evaluate this specific intramedullary distal fibular fixation system that contains a unique-proximal fixation mechanism within the canal itself. This technique was used for a variety of unstable ankle fractures and was shown to be both safe and effective, and will help guide future prospective studies comparing outcomes with the gold-standard plate and screw fixation.

To fix or not to fix: a novel approach to the safe management of unstable open medial malleolar fractures

Displaced medial malleolar fractures, either in isolation or as part of an unstable ankle fracture dislocation, are conventionally treated with internal fixation. We outline the case of a 76-year-old man with diabetes presenting with a grossly deformed open ankle fracture and extruded tibia through a large medial wound. Following irrigation, wound debridement and minimally invasive fibular fixation, the medial fracture reduced anatomically. Contrary to traditional teaching, the medial malleolus was left without fixation. The patient mobilised partially weight-bearing, progressing to both clinical and radiographic union by 3 months. Nine months following an injury, he walks unaided, can squat and drive and has no medial pain or instability with an Olerud–Molander Ankle Score of 80/100, indicating a good outcome. This is the first reported case of such unique management in the literature and highlights the potential to treat open medial malleolar fractures safely without fixation, particularly when concerned about the soft tissue envelope.