SLR - October 2022 - Daniel Chu, DPM
Reference: Hodgkins CW, Fleites J. Fibula Nailing: A Retrospective Review of 110 Consecutive FibuLock Nails. J Orthop Trauma. 2022;36(7):366-369. doi:10.1097/BOT.0000000000002329Level of Evidence: IV
Scientific Literature Review
Reviewed by: Daniel Chu, DPM
Residency Program: Scripps Mercy Hospital, San Diego, California
Podiatric Relevance: Ankle fractures are one of the most common fractures that are encountered by foot and ankle surgeons. It is widely accepted that unstable ankle fractures require open reduction and internal fixation, with a plate and screw construct being the gold standard for fixation. However, the formal open incision has been shown to be associated with complications including wound dehiscence, infection, and prominent hardware, which may require a secondary surgery to remove the hardware. With fibula nailing, the surgical approach is more minimally invasive, and the smaller incisions can result in less disruption to the fracture site. This can be associated with lower complication rates and allow faster union, which may allow earlier weight bearing and return to work and play. The FibuLock fibula nail design incorporates both distal and proximal fixation technology, and the authors in this study hypothesize that: 1) this design would prove an effective alternative to plating of unstable lateral malleolar fractures with low complication rates; 2) the minimally invasive nature of reduction and insertion would minimize wound complications; 3) and the no-profile construct would decrease the need for second surgeries.
Methods: A retrospective review was conducted on 110 patients with consecutive ankle fractures treated with the FibuLock fibula nail by a single surgeon. Exclusion criteria included associated tibial shaft fracture, pilon fracture, open fracture, and older than 80 years of age or younger than 18 years. Using the OTA/AO classification, there were 92 44B and 18 44C fracture types. Surgical reduction was assessed by a single surgeon based on direct intraoperative visualization, intraoperative fluoroscopy, and all follow-up weight-bearing radiographs at 6 weeks, 10 weeks, 16 weeks, 6 months, and 1 year. Chart review was conducted for other clinical information as well as intraoperative and postoperative complications.
Results: 102 patients were included in the study. Intraoperatively, there were 2 fractures that had significant comminution that required plating, so they were considered failures of the procedure. 8 fractures were reduced percutaneously through stab incisions for the clamp, and 94 fractures utilized mini open incisions averaging 3 cm. Average time to weight bearing in a boot was 4.9 weeks, and time to 100% weight bearing without a walking aid in a boot averaged 9.31 weeks. Osseous union was evident in all cases at an average of 7.2 weeks based on callus on radiographs and lack of pain. There were no postoperative infections, delayed wound healing, delayed unions, malunions, nonunions, or any additional surgeries. There was one case of iatrogenic incisional superficial peroneal nerve neuroma documented.
Conclusions: FibuLock fibula nail resulted in anatomic healing in almost all of the fractures, and there was a very low complication rate with no cases requiring hardware removal. The device allowed early aggressive ankle motion and weight bearing. Based on these findings, fibula nailing does not need to be only used for soft tissue compromised patients and can be a safe and effective alternative in fixing unstable lateral malleolar fractures.