SLR - March 2021 - Syeda Z. Kazmi

Plate Versus Lag Screw Only Fixation of Unstable Ankle Fractures Involving the Fibula in Adolescent Patients

Reference: Paez CJ, Lurie BM, Bomar JD, Upasani VV, Pennock AT. Plate Versus Lag Screw Only Fixation of Unstable Ankle Fractures Involving the Fibula in Adolescent Patients. J Pediatr Orthop. 2021;41(2): e161-e166. 

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Syeda Z. Kazmi, DPM
Residency Program: Inspira Medical Center – Vineland, NJ

Podiatric Relevance: Podiatric surgeons commonly diagnose and treat unstable ankle fractures. There is a substantial amount of research that has been published on  plate versus lag screw technique for unstable ankle fractures in the adult population but not in the adolescent population. Most studies in the past with the adolescent population focused on surgical versus conservative treatment, but this research is the first to compare the two surgical techniques of plate versus lag screw only fixation.

Methods: A retrospective study (2011-2019) was done at a pediatric level-1 trauma center. All 83 adolescents included in the study had unstable oblique distal fibular fracture, were less than 20 years of age, and had a follow-up until radiographic union. The adolescent group was non-randomly divided into two groups: plate fixation (n = 51) and lag screw fixation (n = 32). Chart and radiographic review were conducted for comparison. Demographic data included age, patient-reported outcome, BMI, sex, fracture pattern, Weber classification, and fracture length. Surgical data included tourniquet time, incision length, immobilization time, weight-bearing restriction time, and if there was posterior malleolus fixation. Clinical outcomes measurement was done utilizing SANE, FAAM ADL, patient reported ADL function, FAAM sports, patient-reported sports, satisfaction 0-10, return to all activities sports, function, implant bothersome, and implant removal. Statistical analysis was performed on all the obtained data. 

Results: From the 83 participants, 50 percent followed up at a mean of about four years. Both plate and lag screw surgical technique group achieved one hundred percent healing rate without any reduction loss. There was a statistically significant difference in average tourniquet time, where the lag screw group was shorter at approximately 49 minutes versus approximately 64 minutes in the plate group (p = 0.001).  Lag screw fracture length was significantly longer at 5.4 centimeters compared to the plate technique group at 1.3 centimeters (p = 0.037). The skin incision was longer for the plate technique at 7.9 centimeters versus the lag screw group at 6.2 centimeters (p = 0.008). A symptomatic implant was 3.8 times more likely in the plate technique than the lag screw group (p = 0.044). Female gender was higher in the plate group (p = 0.026). No other statistical significance was found in any of the other variables. 

Conclusions: This study focused on the adolescent population but the results are applicable and support previous literature comparing the two surgical techniques in the adult population. Lag screws are as effective as the plate technique in the adolescent population. However, the lower rates of implant bothersome, shorter incision length, and shorter operative time in the lag screw group adds additional benefits when compared to the plate technique. One of the limitations of the study was the non-randomized grouping as surgical technique was based on surgeon preference. Although not statistically significant, the lag screw group had a longer follow-up (eight more months) than the plate group. A randomized control study with longer follow-up and more participants may need to be performed to determine if one treatment option is more effective than the other in the adolescent population. 

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