Background: Open reduction and internal fixation (ORIF) methods, primarily plates and screws, remain the standard of treatment for distal fibular fractures. This study evaluates the use of a cannulated intramedullary screw as a minimally invasive treatment method for distal fibular fractures, which has not been reported in the current literature. Methods: This retrospective study included 45 patients with distal fibular fractures treated with cannulated intramedullary screw fixation. All patients included in the cohort had a soft-tissue condition and/or comorbidity. The mean age was 54 years. The Weber classification system was used to assess the type of fracture. Average time to union, average time to weight bearing, and complications were monitored. Results: Reduction quality criteria were collected using previously published guidelines. Accordingly, reduction was determined to be good in 25 cases, fair in 15, and poor in 5. A low complication rate of 4% was reported. Average time to union was 10 weeks (range = 8-36 weeks), whereas average time to weight bearing was 14 weeks (range = 8-40 weeks). Conclusion: Cannulated intramedullary screw fixation can serve as a minimally invasive, safe, and satisfactory treatment for distal fibular fractures with resulting high union rates and low complication rates.
Levels of Evidence: Level IV: Retrospective, case series
KannusPPalvanenMNiemiSParkkariJJärvinenM.Stabilizing incidence of low-trauma ankle fractures in elderly people Finnish statistics in 1970-2006 and prediction for the future. Bone. 2008;43:340-342.
BuglerKEWatsonCDHardieARet al. The treatment of unstable fractures of the ankle using the Acumed fibular nail: development of a technique. J Bone Joint Surg Br. 2012;94:1107.
4.
KovalKJLurieJZhouWet al. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma. 2005;19:635-639.
5.
LamontagneJBlachutPABroekhuyseHMO’BrienPJMeekRN.Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002;16:498-502.
6.
MeyerTLJrKumlerKW.A.S.I.F. technique and ankle fractures. Clin Orthop Relat Res. 1980;150:211-216.
7.
HoinessPEngebretsenLStromsoeK.The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int. 2001;22:642-648.
8.
BeauchampCGClayNRThextonPW.Displaced ankle fractures in patients over 50 years of age. J Bone Joint Surg Br. 1983;65:329-332.
9.
SchepersTVan LieshoutEMDe VriesMRVan der ElstM.Increased rates of wound complications with locking plates in distal fibular fractures. Injury. 2011;42:1125-1129.
10.
LeeYSHuangHLLoTYHuangCR.Lateral fixation of AO type-B2 ankle fractures in the elderly: the Knowles pin versus the plate. Int Orthop. 2007;31:817-821.
11.
PritchettJW.Rush rods versus plate osteosyntheses for unstable ankle fractures in the elderly. Orthop Rev. 1993;22:691-696.
12.
RajeevASenevirathnaSRadhaSKashayapNS.Functional outcomes after fibula locking nail for fragility fractures of the ankle. J Foot Ankle Surg. 2011;50:547-550.
13.
StraussEJEgolKA.The management of ankle fractures in the elderly. Injury. 2007;38(suppl 3):S2-S9.
14.
WukichDKJosephARyanMRamirezCIrrgangJJ.Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int. 2011;32:120-130.
15.
AsloumYBedinBRogerTCharissouxJLArnaudJPMabitC.Internal fixation of the fibula in ankle fractures: a prospective, randomized and comparative study: plating versus nailing. Orthop Traumatol Surg Res. 2014;100(4, suppl):S255-S259. doi:10.1016/j.otsr.2014.03.005
16.
LyndeMJSautterTHamiltonGASchuberthJM.Complications after open reduction and internal fixation of ankle fractures in the elderly. Foot Ankle Surg. 2012;18:103-107.
17.
AndersonSALiXFranklinPWixtedJJ.Ankle fractures in the elderly: initial and long-term outcomes. Foot Ankle Int. 2008;29:1184-1188.
18.
McFerranMASmithSWBoulasHJSchwartzHS.Complications encountered in the treatment of pilon fractures. J Orthop Trauma. 1992;6:195-200.
19.
GustiloRBAndersonJT.Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453-458.
20.
IsikCTechimelOAkmeseRFiratATahtaMBozkurtM.The comparison of plate-screw and tension band techniques in the osteosynthesis of Danis-Weber type A and B lateral malleolar fractures.Acta Orthop Traumatol Turc. 2013;47:27-31.
21.
LunnJVRahmanKUMaceyAC.Functional outcome after lag screw fixation of lateral malleolar fractures. J Foot Ankle Surg. 2003;9:109-112. doi:10.1016/S1268-7731(03)00015-8
22.
McKennaPBO’SheaKBurkeT.Less is more: lag screw only fixation of lateral malleolar fractures. Int Orthop. 2007;31:497-502. doi:10.1007/s00264-006-0216-6
23.
TambeADSwamiKMuraliSRBrowneAO.A new technique for fixing unstable Weber B fractures of the ankle: evaluation of outcome, in the elderly and those with poor skin envelope. J Foot Ankle Surg. 2004;10:169-176. doi:10.1016/j.fas.2004.06.006
24.
TsukadaSOtsujiMShiozakiAet al. Locking versus non-locking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial. Int Orthop. 2013;37:2451-2456. doi:10.1007/s00264-013-2109-9
25.
JainSHaughtonBABrewC.Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes. J Orthop Traumatol. 2014;15:245-254.
26.
BrownOLDirschlDROmbremskeyWT.Incidence of hardware related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma. 2001;15:271-274.
27.
LittleMTBerkesMBLazaroLESculcoPKHelfetDLLorichDG.Complications following treatment of supination external rotation ankle fractures through the posterolateral approach. Foot Ankle Int. 2013;34:523-529.
28.
SmithGMackenzieSPWallaceRJCarterTWhiteTO.Biomechanical comparison of intramedullary fibular nail versus plate and screw fixation. Foot Ankle Int. 2017;38:1394-1399.
29.
CoifmanOBariteauJTShazarNTenenbaumSA. Lateral malleolus closed reduction and internal fixation with intramedullary fibular rod using minimal invasive approach for the treatment of ankle fractures [published online September 7, 2017]. Foot Ankle Surg. doi:10.1016/j.fas.2017.08.008
30.
GossDAJrRebCWPhilbinTM.Anatomic structures at risk when utilizing an intramedullary nail for distal fibular fractures: a cadaveric study. Foot Ankle Int. 2017;38:916-920.
31.
SwitajPJFuchsDAlshouliMet al. A biomechanical comparison study of a modern fibular nail and distal fibular locking plate in AO/OTA 44C2 ankle fractures. J Orthop Surg Res. 2016;11:100.
32.
DingemansSALodeizenOAGoslingsJCSchepersT.Reinforced fixation of distal fibula fractures in elderly patients: a meta-analysis of biomechanical studies. Clin Biochem (Bristol, Avon). 2016;36:14-20.
33.
ChallangundlaSRShewaleSCreeCHawkinsA. Intramedullary fixation of lateral malleolus using fibula rod system in ankle fractures in the elderly [published online April 27, 2017]. Foot Ankle Surg. doi:10.1016/j.fas.2017.04.015
34.
RehmanHMcMillanTRehmanSClementAFinlaysonD.Intramedullary versus extramedullary fixation of lateral malleolus fractures. Int J Surg. 2015;22:54-61.
35.
AppletonPMcQueenMCourt-BrownC. The fibula nail for treatment of ankle fractures in elderly and high-risk patients. Tech Foot Ankle Surg. 2006;5:204-208.
36.
McLennanJGUngersmaJA.A new approach to the treatment of ankle fractures: the Inyo nail. Clin Orthop Relat Res1986;(213):125-136.
37.
CostiganWThordarsonDBDebnathUK.Operative management of ankle fractures in patients with diabetes mellitus. Foot Ankle Int. 2007;28:32-37. doi:10.3113/FAI.2007.0006
38.
NohJHRohYHYangBGKimSWLeeJSOhMK.Outcomes of operative treatment of unstable ankle fractures: a comparison of metallic and biodegradable implants. J Bone Joint Surg Am. 2012;94:e166. doi:10.2106/JBJS.K.01221
39.
BajwaAGantzDE.Cerclage wire and lag screw fixation of the lateral malleolus in supination and external rotation fractures of the ankle. J Foot Ankle Surg. 2005;44:271-275. doi:10.1053/j.jfas.2005.04.008
40.
ZhenhuaFWaizyHMingXWushengK.Lateral malleolus hook plate for comminuted Weber A and B fractures: a retrospective study. Indian J Orthop. 2013;47:364-369. doi:10.4103/0019-5413.114918
41.
StewartCMKinerDNowotarskiP.Intramedullary nail fixation of fibular fractures associated with tibial shaft and pilon fractures. J Orthop Trauma. 2013;27:e114-e117. doi:10.1097/BOT.0b013e3182694a2d
42.
EnglesD.Use of cannulated screws in hand and wrist surgery. In: CapoJTTanV eds. Atlas of Minimally Invasive Hand and Wrist Surgery. 1st ed. New York, NY: Informa Healthcare; 2008.
