SLR - May 2015 - Jeffrey Olson

Internal Fixation of the Fibula in Ankle Fractures. A Prospective, Randomized and Comparative Study: Plating Verse 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 Verse Nailing. Orthop Traumatol Surg Res. 2014 Jun; 100 (4 Suppl):S255-9.

Reviewed By: Jeffrey Olson, DPM
Residency Program: Botsford Hospital, Farmington Hills, MI

Podiatric Relevance: The standard for management of ankle fractures has generally been the use of internal fixation using plating and screw combinations. However, many percutaneous fixation techniques have been proposed and implemented with good results in higher risk patients. More recently, a technique has been proposed to use intramedullary fibular nailing to achieve bony union in ankle fractures. This article compares the results of internal fixation with standard plate fixation and describes a technique using a morphologically curved intramedullary nail (Epifisa® FH intramedullary nail) inserted into the distal fibula.  

Methods: The study design was a prospective, randomized, single blind, multi-surgeon study including 71 patients. Inclusion criteria consisted of: closed fractures, isolated displaced fractures of the lateral malleolus, inter- and supra tubercular bimalleolar fractures and trimalleolar fractures. Patients received all adjunctive procedures as warranted by the fracture pattern. Plate fixation was performed in thirty-five patients in the usual standard technique with Synthes AO reconstruction locking compression plates with 4.0mm cancellous and 3.5mm cortical screws. Intramedullary nailing was performed in thirty-six patients using the Epifisa® FH Orthopedics intramedullary nail with the 9mm self-tapping screw inserted distally into the cancellous bone of the tip of the fibula. Patients were then immobilized for six weeks in a plastic boot cast followed by progressive weight-bearing for one month. The main criteria assessed were bone union one year after surgery evaluated by x-ray with secondary criteria of complications, functional tests, and Olerud-Molander scores. Qualitative variables were compared using the Chi2 test and the Fisher exact test. Quantitative variables were compared using the Mann and Whitney test for unpaired series.

Results: Interestingly, of the thirty-six patients with intramedullary nailing, seven patients initially failed the surgical procedure due to technical reasons (severe fractures, narrow medullary canal, persistent tibiofibular diastasis). These patients were ultimately converted to plate fixation and taken out of the total numbers being analyzed independently (four of the seven patients dropped out of the study). Overall there was significant difference between the two groups in the area of postoperative complications and functional scores. Complications were fewer in the intramedullary nailing compared with plate fixation, 7 percent vs 45 percent, with skin necrosis being the most common complication in plate fixation. Functional score were broken down into excellent/good/fair/poor. Kitoka scores for plate fixation were 25.00 percent/53.13 percent/9.38 percent/12.50 percent and intramedullary nailing were 78.57 percent/21.43 percent/0.00 percent/0.00 percent. Olerud-Molander scores for plate fixation were 37.50 percent/43.37 percent/ 6.25 percent/12.50 percent and intramedullary nailing were 100.00 percent/0.00 percent/0.00 percent/0.00 percent. Bone union was obtained in 94 percent of the cases in the plate fixation group and 100 percent in the intramedullary nailing group, which was not significant (p=0.5605).

Conclusions: The intramedullary nail used in this study was an Epifisa® nail measuring 5mm in diameter with a maximum length of 130mm. In the few studies involving this system, there has been some criticism of the nail not being rigid enough. In this study however, the intramedullary nail held up well and provided good bone union, functional scores, and even a better complications profile when compared with a locking plate. Although the data suggests that this system is comparable to plate fixation, the intramedullary nailing system cannot used for all ankle fractures types and clinical judgment should be used before and during surgery. Other confounding issues presented in this study is that seven of the thirty-six patients who received the intramedullary nailing system had technical issues with placement of the nail and were ultimately converted to plate fixation. Overall, this system when used in the appropriate setting can provided reliable results and can be a viable option for higher risk patients.   

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