SLR - May 2021 - Shivang M. Shah

Intramedullary Nailing as an Alternative to Plate Fixation in Patients with Distal Fibular Fracture

Reference: Kho DW, Kim HJ, Kim BJ, Choi SM. Intramedullary Nailing as an Alternative to Plate Fixation in Patients with Distal Fibular Fracture. Orthop Traumatol Surg Res. 2020 Feb;106(1):149-154. 

Level of Evidence: 1 (Randomized Control Trial)

Scientific Literature Review

Reviewed By: Shivang M. Shah, DPM
Residency Program: AMITA Saint Joseph Hospital – Chicago, IL

Podiatric Relevance: Distal fibular fractures account for 10 percent of all fractures per year. It is important for these fractures to be reduced and held together with rigid fixation to allow for proper anatomic alignment as well to achieve bony union. There are a number of different type of internal fixations available including compression screws and plate fixation (PF), but these have limitations due to various complications. Intramedullary Nails (IMN) provide a solution by being minimally invasive as well as aiding in avoiding the number of complications and has been found to be comparable to PF. The purpose of this study is to compare functional and radiographic outcomes of both the intramedullary nail and plate fixation groups, as well as look at the rate of bony union and the frequency of postoperative complications between both groups.

Methods: This article was a single center, randomized control trial. 70 patients were selected initially who had a displaced distal fibular fracture, who had open or closed reduction and who were present through the follow up. Treatment was performed only by the senior author. Protocol for insertion of the intramedullary nail was discussed and an Accumed fibular nail was inserted. Plate fixation group used a lag screw with a locking plate for fixation. Any associated fractures were treated accordingly. Functional outcome measures were recorded and calculated using American Orthopaedic Foot and Ankle Society Scores (AOFAS) and the Olerud Molander Ankle Scores (OMAS). Radiographic outcomes were measured at three, six, nine and 12 months post op on a 1-4 scale. Complication rates were also assessed. Statistical analysis expressed as mean +- SD, Students t-test, and Mann-Whitney U test. A p-value of <.05 was considered statistically significant.

Results: The study showed significant time-dependent functional outcomes in both the AOFAS and OMAS in the IMN group compared to the PF group at three months. At six months there were significant improvements in functional outcomes for AOFAS with IMN compared to PF. There were no significant differences between both functional outcomes with both AOFAS and OMAS. All patients reached bony union radiographically at 12 months in both groups. Fewer post-operative complications were noted in the IMN group compared to PF group, and this was found to be significant at 12 months.

Conclusions: The results showed significant improvement with time with the IMN compared to the PF as well with significant decrease in frequency of post-operative complications. The authors discussed that there are benefits to IMN in that it is a load-sharing implant compared to PF which is a load-bearing implant. They do note some disadvantages to the study in that it was a one center study with a limited subset of patients. The authors also discussed that further studies need to be done comparing IMN to PF. IMN fixation for distal fibular fractures can be a very valuable tool for podiatrists. It has been shown to be an effective tool in treating other orthopedic concerns. It offers patients the ability to return to activity quicker while at the same time reducing possible complications. 

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