SLR - June 2015 - Alexander Mount

Internal Fixation of the Fibula in Ankle Fractures. A Prospective, Randomized and Comparative Study: Plating Versus Nailing

Reference: Asloum Y, Bedin B, Roger T, Charissoux JL, Arnaud JP, Mabit C. Internal fixation of the fibula in ankle fractures. A prospective, randomized and comparative study: plating versus nailing. Orthop Traumatol Surg Res. 2014 Jun;100(4 Suppl):S255-9.

Scientific Literature Review

Reviewed By: Alexander Mount, DPM
Residency Program: Morristown Memorial Hospital

Podiatric Relevance: The debate regarding minimally invasive versus open surgical techniques remains among the most polarizing in foot and ankle surgery. Given the frequency of ankle fractures and the complications associated with them there is an increased need for evidence based medicine to elucidate the best way to treat them. In the present study plate fixation was compared with intramedullary nailing for closed displaced fibular inter-tubercular or supra-tubercular fractures that occurred in isolation or as part of a bimalleolar or trimalleolar fracture.

Methods: In this prospective randomized single blinded study, plate fixation with a Synthes AO reconstruction locking compression plate utilizing 4.0mm cancellous and/or 3.5mm cortical screws was compared with intramedullary nail fixation with a FH Orthopedics’ Epifisa® intramedullary nail, a 5mm diameter curved intramedullary nail with a 9mm self-tapping head that locks the nail in place. Inclusion criteria included closed displaced fibular inter-tubercular or supra-tubercular fractures that occurred in isolation or as part of bimalleolar or trimalleolar fractures. Fibular fractures were excluded from the study if the fracture was more than 9cm proximal to the tip of the fibula, open, or co-occurred with pilon, talar, or pathologic fractures.

The surgeries were performed by a group of four senior and five junior surgeons. Peri-operative management was the same for patients in both groups. Pre-operative antibiotics were administered. Intra-operatively the patients were positioned supine with an ipsilateral bump, and a pneumatic thigh tourniquet was placed. Adjunct procedures such as medial collateral ligament repair, posterior malleolar ORIF with anteroposterior screw fixation, and/or medial malleolar tension band wiring or screw fixation were performed as indicated. Post-operatively the patients were immobilized for six weeks in a plastic boot cast, weight bearing was progressive over a one month period, and formal rehabilitation was started after cast removal.

Outcome measures included bony union after one year (evaluated radiographically), development of post-operative complications (skin necrosis, sepsis, secondary displacement, or algodystrophy, and functional outcomes as measured by scores on the Kitaoka clinical rating system and the Olerud-Molander ankle fracture scale.

Results: Plate fixation and intramedullary nailing were performed on 32 and 28 fractures respectively. Seven fractures that were originally assigned to the intramedullary nailing group were converted to the plate fixation because of comminution of the fracture, narrow fibular diameter, or persistent syndesmotic instability and were excluded from the study. There was no statistically significant difference in type of fracture, cause of trauma, patient age, patient gender, or side of the injury.  Bony consolidation at one year post-op was not statistically significant between groups (P=0.5605). However, the rate of postoperative complications was higher in the plate fixation group than the intramedullary nail group (56 percent (18/32) vs. 7 percent (2/28), respectively P=0.0014).  Of the complications that patients developed in the plate fixation group skin necrosis was the most common (9/32, 43.75 percent), followed by algodystrophy, (7/32, 15.63 percent), 2/32 (6.25 percent) developed infection, and 2/32 (6.25 percent) secondary displacement. The 7 percent (2/28) of the intramedullary nail patients with complications developed algodystrophy.

The functional outcomes on both the Kitaoka clinical rating system and the Olerud-Molander ankle fracture scale were superior in the intramedullary nail group (P=0.0011 and <0.0001 respectively). On the Kitaoka scale 78.57 percent of nail patients had excellent results. The remaining 21.43 percent had good results. The plate fixation group had 25 percent excellent, 53.13 percent good, 9.38 percent fair, and 12.5 percent poor results. On the Olerud-Molander scale 100 percent of intramedullary nail patients had an excellent result, whereas patients who were treated with plate fixation had 37.5 percent excellent, 43.75 percent good, 6.25 percent fair, and 12.5 percent poor results.

Conclusions:  Given the superior functional outcomes and minimal surgical complications the current study strongly supports the use of intramedullary nailing in non-comminuted fibular fracture without syndesmotic injury. While the results appear promising this study contains some short comings. The study included a total of nine surgeons and with no mention of the role each of them played during each surgery. Differences in technique or surgical experience between junior and senior surgeons could potentially affect patient outcomes. The article did not specify whether locking, non-locking, or hybrid plating was utilized, which could have affected the rate of complications and secondary displacement in particular. The article also did not define what skin necrosis, sepsis, and secondary displacement entailed nor did it specify what criteria were used to diagnosis algodystrophy. Another potential issue is that FH Orthopedics Epifisa® is not currently available in the United States (although a company representative stated in a personal communication that the Epifisa® will be FDA approved and available in July of 2015). While Acumed® currently has an intramedullary rod available the results of this study may not be generalizable to it. Regardless, further research in a larger number of patients should be pursued. Despite its shortcomings this study is clinically relevant and intramedullary nailing should be considered in non-comminuted fibular fracture particular in patients predisposed to wound complications.

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