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research-article2014
FAIXXX10.1177/1071100714555712Foot & Ankle InternationalMitchell et al
Topical Review
Fixation of Distal Fibula Fractures: An Update
Foot & Ankle International® 2014, Vol. 35(12) 1367–1375 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714555712 fai.sagepub.com
Justin J. Mitchell, MD1, LCDR James R. Bailey, MD, MC, USN3, Anthony E. Bozzio, MD1, Ryan R. Fader, MD1, and Cyril Mauffrey MD, FACS, FRCS1,2 Level of Evidence: Level V, expert opinion. Keywords: trauma, outcome studies, biomechanics, tendon disorders, statistical analysis
Introduction Fractures of the fibula are common injuries treated by orthopaedic surgeons and often require surgical stabilization. Nevertheless, controversy remains with regard to the optimal method of fixation. Studies have demonstrated that anatomic reduction and fixation of the distal fibula improves outcomes in patients with an unstable ankle mortise.12,25 Traditionally, fixation involved the use of a lateral one-third tubular plate with bicortical screws proximal to the fracture site and either unicortical or bicortical screws for distal fragment fixation 2,4,12,19 However, some have cited potential disadvantages of this lateral fixation, including the possibility of intra-articular screw placement, painful hardware, inferior biomechanical strength, inadequate distal fixation, loss of fixation, and wound problems.4,5,12,15,20,21,37 In recent years, alternative methods of fixation have been proposed including posterolateral plate fixation, locking plate constructs, and the use of intramedullary devices. Since the advent of these alternative techniques, there has been continued discussion and research regarding the use of these fixation methods. As this is a potential area for continued and future research and interest, we present a review of available literature to provide an update on current fixation techniques as well as the challenges, benefits, and drawbacks of each.
Surgical Anatomy and Approaches The distal fibula may be approached using either a direct lateral or posterolateral approach. The direct lateral approach is the most commonly utilized when performing either lateral or posterior fixation. However, choice of approach is influenced by surgeon preference, fracture type and configuration, associated injuries, and status of the skin. With the direct lateral approach, exposure is relatively straightforward. Nevertheless, care must be taken to protect both the sural nerve posteriorly and the superficial peroneal nerve anteriorly. The latter usually exits the crural fascia
approximately 12 to 14 cm above the ankle before dividing in to the intermediate and medial dorsal cutaneous nerves.3 This anatomy is particularly relevant in fractures at or above the level of the syndesmosis, where the superficial peroneal nerve crosses directly in the field of dissection, placing it at risk for transection or irritation. The posterolateral approach to the distal fibula exploits the interval between the peroneal tendons and the flexor hallucis longus. With the patient in a lateral decubitus or prone position, the incision is typically placed halfway between the posterior border of the distal fibula and the lateral border of the Achilles tendon. Following skin incision, the sural nerve can be encountered and must be protected and gently retracted. The peroneal tendon sheath is incised in line with the incision. The peroneal tendons are retracted anteriorly to expose the fibula and the flexor hallucis longus muscle medially. Elevating the lateral fibers of the flexor hallucis longus provides further exposure of the fibula and the posterior tibia. Distal fibula fractures (and when necessary, a distal tibia fracture) can be debrided, reduced, and stabilized through this approach. This incision; however, is often made slightly posterior if the goal is posterior plating.
Surgical Fixation Techniques Lateral Plating A nonlocking plate has traditionally been used for direct lateral fixation of the distal fibula (Figure 1). Proponents of 1
University of Colorado Hospital, Department of Orthopaedic Surgery, Aurora, CO, USA 2 Denver Health Medical Center, Department of Orthopaedic Surgery, Denver, CO, USA 3 Naval Hospital–Bremerton, Department of Orthopaedic Surgery, Bremerton, WA, USA Corresponding Author: Cyril Mauffrey, MD, FACS, FRCS, Denver Health Medical Centre, 777 Bannock Street, Denver, CO 80204, USA. Email: [email protected]
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Foot & Ankle International 35(12) used and has demonstrated equivalency to plate fixation in young patients with good bone stock. This technique is safe and effective, with limited dissection and less prominent hardware.17,34 However, it is reserved for use in long oblique fractures and is not a viable option for individuals with comminuted fractures, osteoporosis, limited compliance with weightbearing, or irreducible syndesmotic injury.34 Various authors have reported unsatisfactory fixation and decreased fixation strength with unicortical cancellous fixation, especially in osteoporotic or comminuted bone.14,16 This can lead to loss of fixation as well as delayed or nonunion.2,4,6 While locking and posterior plating may obviate these risks, authors have attempted to provide means by which standard nonlocking constructs with adjunct fixation could be used, including the use of carefully placed bicortical screws in the distal fragment or tetracortical fixation using tibia-pro-fibula (syndesmotic) screws14,20,24 (Figure 3). Panchbhavi et al24 investigated this strategy and found that when compared with the same construct without additional screws, tetracortical fixation demonstrated a 9% increase in torque to failure, 24% increase ability to withstand external rotation, and a 34% increase in energy before failure of the construct. This fixation technique adds little operative time, is inexpensive, and is a technically straightforward method to increase the stability of the construct.24
Posterior Plating
Figure 1. Preoperative (A) anterior/posterior and (B) lateral radiographs of a displaced fibula fracture. Postoperative (C) anterior/posterior and (D) lateral views of a direct lateral plate on the fibula with the use of an interfragmentary compression screw.
direct lateral plating maintain that this construct is simple, provides sufficient biomechanical stability, and will not lead to peroneal tendon pain or irritation. Techniques have evolved over time (including the use of locked plating constructs as discussed in the following), but fixation using this plate typically calls for at least 2 bicortical screws proximal to the fracture site and 2 unicortical cancellous screws distally. There has been debate regarding the distal fixation and the use of bicortical versus unicortical screws.20,29 Proponents of the use of bicortical screws argue that this provides superior fixation to unicortical fixation with cancellous screws.15,18 Conversely, those in favor of unicortical screw placement point to the possibility of intra-articular screw placement with the use of bicortical screws.38,40 The use of an interfragmentary lag screw (Figure 1) has been employed for increased compression and stability in oblique fibular fractures.19,20 Lag screw only fixation of the long oblique fracture of the lateral malleolus has also been
In 1982 Brunner and Weber proposed the use of a posterior antiglide plate as a new method of fibular fixation. They concluded that posterior plating was advantageous as it was biomechanically superior and avoided the soft tissue complications associated with subcutaneous plate placement.6 The use of posterior plating in lieu of lateral fixation remains controversial. Advocates of posterior plate application argue that the concern for intra-articular screw penetration is voided with posterior to anterior screw placement. Other potential benefits include less dissection and operative time, minimum bending of the plate, and the fact that distal screw fixation may be unnecessary.30,35,37,39,40 Nevertheless, this technique entails dissection of the peroneals and potential irritation by the plate. Similar to lateral plating, a one-third tubular plate is typically used. At least 2 bicortical nonlocking screws are placed through the most proximal portion of the plate (Figure 2). The posterior plate and the typical orientation of the fracture line (apex postero-superior) create an axilla. The plate configuration thereby forms an antiglide construct, and although used by some surgeons, distal fragment fixation is not required.15,21,30,39,40 In fact, some authors advocate not filling the distal hole with a screw as they believe that screw head is what causes peroneal irritation with this construct.37 An interfragmentary compression screw may also be placed through the plate perpendicular to
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Figure 2. (A) Anterior/posterior and (B) lateral radiographs of a displaced fibula fracture with posterior malleolar and syndesmotic injury. (C) Demonstrates posterior plating construct for a distal fibula fracture in conjunction with posterior plate fixation of the posterior malleolar fragment and TightRope (Arthrex, Napes, FL) fixation of the syndesmosis.
the fracture in a traditional lag fashion. This requires planning when placing the plate such that an accessible screw hole is appropriately oriented. Wissing et al40 reported on the potential advantages of posterior antiglide plating in a retrospective review of their cases’ arguing that in cases of severe soft tissue injury, a lateral plate caused more skin irritation. In addition, the shape and bony structure of distal fibula is not uniform, and a lateral plate must be contoured in order to sit directly against the bone, which may result in a biomechanically disadvantaged construct. Finally, the thin lateral cortex gives rise to decreased purchase with distal laterally based screws that can penetrate the distal tibiofibular and fibulotalar joints.
Distal Fibular Locked Plating Short, oblique fractures of the distal fibula are typically amenable to fixation using the techniques described previously. However, in patients with diminished bone stock or severely comminuted fractures, obtaining adequate fixation can be challenging. Locking plates have been reported as an alternative form of fixation in these cases.13,16,21,24 Locked plating is well described and relies on the interaction between plate and screw to create a fixed angle device. The periarticular nature of the distal fibula makes distal bicortical fixation difficult. The biomechanical advantages of a fixed angle device, however, allows for the use of unicortical screws as it obviates the need for both bicortical fixation and compression between the plate and bone to stabilize the fracture.11,38,41 The locking mechanism prevents screw
toggle and back out, which may be exacerbated with the use of conventional plates in patients with deficient bone stock.41 Recently, there has been increased interest in the use of distal fibular locking plates in comminuted or osteoporotic fractures.9,11,16,28 Locking plates exist in one-third tubular form or in anatomically contoured options. These plates are typically larger and stronger with a flare at the distal aspect of the fibular metaphysis to provide multiple options for locking unicortical distal fixation. Smaller (eg, 2.7 mm) screws may be incorporated into the plate design. In addition to options for increased distal fixation, minimally invasive plate osteosynthesis with locked plating has also been used in those patients with increased risk for wound complications, infection, and high rates of complications such as the elderly and in those with diabetes or neuropathy.11,13,16,21
Intramedullary Fibular Nail Locking plates have shown promise in treating comminuted or osteoporotic fractures of the distal fibula, but potential drawbacks exist. Plate fixation may not be possible in fractures with associated soft tissue compromise or in elderly patients with fragile skin.6,10,15 There has therefore been renewed interest in the use of a retrograde screw or fibular nail for such patients (Figure 4).7,27,28,32 Retrograde nail fixation is typically performed through a small transverse incision at the distal aspect of the fibula. A guidewire is inserted in the center of the distal fibula and a reamer is used to breach the distal cortex. Closed reduction
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Figure 3. (A) Photograph of an open ankle fracture dislocation after a ground level fall in a 76-year-old female with osteoporosis and diabetes mellitus type II. (B) Anterior/posterior and (C) lateral radiographs of her immediate reduction are shown, along with (D, E) postoperatiave radiographs demonstrating tetracortical fixation in the setting of a displaced fracture of the lateral malleolus.
is used to hold the fracture in alignment, although minimally invasive reduction and adjunctive Kirschner wire fixation can also be used. Insertion of the nail follows in a retrograde fashion. Proximal and distal locking holes are available to set rotation and alignment, although this is not always performed. Proponents of this fixation cite several advantages including limited exposure, indirect closed reduction, lack of lateral plate prominence, and decreased risk of peroneal tendon irritation.7,27 There are, however, potential disadvantages associated with this strategy including the potential for suboptimal reduction or rotational malalignment. The technique
can also be technically demanding with regard to the placement of percutaneous locking screws, and surgeons that have chosen to forgo this step of the procedure have noted an increased incidence of failure and fracture instability.7
Outcomes/Literature Review Few studies have directly compared various distal fibular fixation techniques. Nevertheless, several recent investigations have examined clinical outcomes, complications, and biomechanical profiles individually.
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Figure 4. (A) Photograph of a right ankle in a 76-year-old female who fractured her distal fibula after stepping off of a curb. Anterior/ posterior radiograph of the injury is shown in (B), and anterior/posterior radiograph of fixation with a fibular nail is shown in (C). (Image courtesy of Acumed, LLC, Hillsboro, OR, Mason Miller, Representative).
Clinical Outcomes Clinical outcomes following fixation of distal fibula fractures focus on fracture union, wound healing, pain relief, restoration of motion, and ankle stability. Several studies have recently reviewed the outcomes for operatively treated ankle fractures. The efficacy of fibular fixation with a lateral plate has been well studied as it relates to union, function, and activity.4,5,10,12,18-20,24,25 Available studies that focus primarily on fixation with one-third tubular plates report that the most important prognostic factors following operative treatment include anatomic reconstruction of the articular surfaces and restoration of fibular length and alignment.2,4,6,12,19,25 Other than malreduction, negative prognostic factors include a delay in fixation greater than 4 weeks post injury, injury to ligamentous structures around the ankle, associated tarsal/ metatarsal fractures, and neuropathy or vasculopathy.5,12,14 Still and Atwood33 recently retrospectively reviewed 41 operatively treated ankle fractures using several operative techniques. Using a modification of the American College of Foot and Ankle Scoring Scale (ACFAS),8 male gender was the only independent variable that statistically increased the likelihood of a satisfactory subjective result. Obesity, smoking, sustaining a high fibular fracture, or undergoing syndesmotic repair decreased the likelihood of a satisfactory result. There have been several studies examining clinical outcomes following posterior plating. In a prospective evaluation of 32 Weber B fractures treated with posterior plating, Ostrum23 reported that 100% of fractures healed uneventfully. There were no nonunions, malunions, wound complications, loss of fixation, or intra-articular screw penetration. Four patients had transient peroneal tendon pain, and 2 patients had later plate removal for symptomatic interfragmentary screw. Twenty of 21 patients who returned a questionnaire were satisfied with their results.
In a review of 93 patients treated with posterior plating, Winkler et al39 reported 67% excellent, 28% good, and 5% poor results at 1-year follow-up. The results were better in young male patients. In another series, Treadwell and Fallat35 reported on 71 Weber B fractures in 70 patients. They reported only 1 case of premature loosening of fixation prior to fracture union and 2 cases of peroneal tendinitis related to the distal positioning of the plate. The symptoms of the latter patients resolved with plate removal. Lamontagne et al15 retrospectively reviewed the outcomes of a lateral plate construct compared to antiglide plating in 193 patients with isolated displaced lateral fibula fractures. There was 1 case of lost fixation in a noncompliant patient in the antiglide group. Otherwise, there were no nonunions or malunions reported and the authors found no statistical significance in terms of operative time, tourniquet time, duration of hospital stay, wound healing complications, or hardware removal rates. They concluded that despite some biomechanical evidence suggesting superiority of antiglide fixation, no statistical difference was seen in clinical outcomes.22 There are few clinical outcome studies specifically evaluating locked plating for distal fibula fractures. Tsukada et al36 performed a randomized controlled trial of 57 patients randomized to either locking plate fixation or nonlocking fixation. No statistically significant difference was observed in the radiographic rate of bone union, SF-36 score, or time to resolution of tenderness at the fracture site.36 Studies regarding outcomes following the use of fibular nails are limited. Appleton et al1 reviewed 37 patients who underwent fixation of unstable ankle fractures with lateral talar shift using a fibular nail. All patients were over the age of 60 years with poor bone quality and/or had significant medical comorbidity or soft tissue trauma that was not amenable to standard fixation. Average follow-up was 58 weeks, and the average Olerud and Molander Score (OMS)
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at final follow-up was 87 out of 100. Average ankle dorsiflexion at final follow-up was within 4 degrees of the uninjured ankle and plantar flexion was within 3 degrees. More than 85% of patients regained ankle motion to within 90% of the uninjured side. Radiographically, all but 1 patient had normal medial clear space and talocrural angle measurements. Another retrospective review of 24 patients with displaced fragility fractures of the distal fibula treated with fibular nail yielded good function and patient satisfaction at 1 year.27 All patients had initial displacement of the fracture with loss of the lateral buttress and went on to fracture union at an average of 8.7 weeks with no wound complications, deep infection, or deep venous thrombosis. Additionally, in their study of 11 patients treated with fibula nailing in elderly osteoporotic patients, Ramasamy and Sherry28 reported excellent results and no wound complications in 88% of cases. In the largest series to date, Bugler et al7 examined the results for 105 patients treated with fibular nail for unstable ankle fractures. Anatomical reduction was achieved in 96% of patients, while 46% had a good outcome, 40% had a fair outcome, and 14% had a poor outcome using OMS. Of note, however, reliability of these results may not be adequate as various configurations of locking screws were used throughout the study process. The initial constructs consisted of distal locking screws with a proximal blocking screw to prevent proximal migration, distal locking screws alone, a syndesmotic screw alone, or no fixation. In this first subset of patients, nail fixation without locking screws achieved rotational and longitudinal stability in only 66% of cases, while those with locking screws demonstrated greater than 90% stability. These results led to a change in technique, which included syndesmotic fixation in addition to a distal locking screw. The current recommended technique calls for antero-posterior distal locking screw to stabilize the distal fragment and allow for rotation and anatomic reduction prior to the insertion of a transverse syndesmotic screw above the fracture, which locks the nail in place.
Soft Tissue Complications Soft tissue complications and painful hardware are cited as the main indications for hardware removal in the postoperative period.5,15,25,31,33,36,37,39 Brown et al5 examined the incidence of soft tissue complications in patients who underwent open reduction and internal fixation of a short oblique fibula fracture with a lateral plate. The authors utilized the Short Form-36 (SF-36) Survey and the Short Musculoskeletal Functional Assessment (SMFA) to obtain patient information and to compare results. Thirty-one percent of patients reported pain overlying their lateral hardware. In general, the SF-36 and SMFA scores at final follow-up were significantly lower for patients who had
pain overlying their lateral hardware than for those who had no pain. Twenty-three percent either had their hardware removed or desired to have it removed. However, only 50% of those who underwent hardware removal had improvement in their lateral ankle pain. To this end, no significant difference was noted in SMFA or SF-36 scores between patients who had their lateral hardware removed and those who had not. These results suggest that the lateral implant may play less of a role in the sensation of pain than other authors have suggested and could be related to cutaneous neuralgia from the incision, concomitant soft tissue injury, or loss of motion related to tibiotalar joint stiffness. With regard to posterior antiglide plating, Winkler et al39 reported that 42 of 93 plates (45%) were removed by 1 year following surgery. The authors did not expand as to why the plates were removed. In that retrospective series reported by Lamontagne et al15 comparing lateral and posterior antiglide fixation of the distal fibula. The authors found a trend toward increased incidence of hardware removal (17% vs 13%), discomfort (12% vs 7%), and wound dehiscence or infection (4% vs 1%) for lateral plate fixation when compared to a posterior antiglide plate, although these differences were not statistically significant. Moreover, they found no statistically significant difference in operative time, tourniquet time, or length of hospital stay. Weber and Krause37 performed a retrospective review of 70 patients treated with posterior antiglide plating in an attempt to identify the location of peroneal tendon lesions as they relate to plate position and how this relates to the need for later hardware removal. In addition to this, they performed dissection of the retromalleolar space in 10 cadavers to study the anatomic variability of the peroneal groove. The plate was removed in 30 patients (43%) because of discomfort and/or physical exam findings suggestive of peroneal irritation. They noted that peroneal tendon lesions were identified in only 9 of the 30 patients (30%) at the time of hardware removal. Two of these 9 patients had peroneal symptoms preoperatively, while the remaining patients had their plates removed at the physician’s suggestion based on physical exam. The authors found that plate position did not correlate with peroneal tendon lesions but rather that placement of a prominent or oblique screw in the most distal hole of the plate did. In cadaveric dissection, the shape of the peroneal groove was uniform and did not contribute to peroneal lesions or irritation. Based on these findings, they recommended not filling the most distal hole of the plate. With regard to locked plating, Schepers et al31 conducted a retrospective clinical study of 205 patients evaluating the complication rates in fixation of the distal fibula using a locking plate compared with those procedures using the nonlocking plate. Of the 40 patients who underwent fixation with locked plating, 7 had wound complications; and of the 165 patients treated with the nonlocking plate, 9 had wound complications. The rate of wound complications
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Mitchell et al observed with the use of the locking plate was significantly higher than that with the nonlocking plate. Meanwhile, Tsukada et al36 did not find any differences in wound complications when comparing locking and nonlocking plates and further did not report any instances of plate removal at 1-year follow-up. These studies differed in that Tsukada’s group used anatomically precontoured locking plates while Schepers et al did not. The data on complications associated with fibular nail fixation are limited. In the previously referenced series by Bulger et al,7 a small subset of all patients (5%) underwent revision surgery for failure of fixation. However, as previously noted, surgical technique changed over time, and early fixation modalities were without locking screws. In this initial subset, 78% of patients experienced no complication. However, 5 patients developed a postoperative infection, and 7 patients failed by loss of fixation. Five of these required revision surgery. With the advent of the new fixation method that included the use of a syndesmotic screw, there was only 1 failure of fixation, and this occurred in a patient that was noncompliant with postoperative weightbearing precautions. Five (5%) patients had postoperative wound infection and 16 patients (15%) underwent hardware removal.
Biomechanics In an attempt to answer the question of biomechanical superiority, Shaffer and Manoli30 performed a cadaveric study comparing the strength of traditional lateral plating with posterior antiglide plating of the distal fibula. Short oblique fractures were created in 24 fresh-frozen cadaveric lower extremities. The extremities were then statically and axially loaded using a biaxial electrohydraulic testing system following reduction and fixation with either a lateral or posterior antiglide plate. Ten fibulae were fixed with a contoured one-third tubular plate without lag screw fixation. Fourteen fibulae were fixed with posterior one-third tubular antiglide plate. Two bicortical 3.5 mm screws were used in the proximal fragment without distal fixation. All specimens were loaded to failure using a supination external rotation force. The last 10 consecutive specimens in the antiglide plate group were retested after being replated with new screw holes and a supplemental lag screw placed through the plate. Fibulae fixed with antiglide plates had a significantly higher failure torque when compared to those fixed with lateral plates. Antiglide plates also demonstrated significantly higher stiffness and energy absorbed before failure (364 Newton meter degrees vs 290 Newton meter degrees). The authors were unable to demonstrate a significant difference between the antiglide plate group and the antiglide plate plus lag screw group. Minihane et al21 subsequently performed a biomechanical comparison between posterior antiglide and lateral
locking plate fixation for displaced short oblique fractures of fibula in osteoporotic bones. Fixation of 18 fresh frozen ankles paired by bone mineral density (BMD) following DEXA scan was performed. Simulated SER IV fractures were created. Nine fractures were stabilized with a lateral one-third tubular locking plate with an independent lag screw while 9 were stabilized with a nonlocking posterolateral antiglide plate augmented with a lag screw through the plate. Significantly higher (P = .01) torque to failure and significantly higher (P = .005) construct stiffness was identified in bones fixed with posterior plates. No differences in angular rotation at failure were identified. Other authors have reviewed biomechanical differences of fibulae fixed with locked plating compared to those fixed with one-third tubular plates.11,13,38,41 Zahn et al41 performed a biomechanical study of 10 cadaveric specimens that underwent open reduction, internal fixation (ORIF) following simulated rotational fibula fractures at the level of the syndesmosis. Five underwent contoured traditional nonlocking fixation while 5 others were stabilized with contoured lateral locking plates. The specimens were then torsionally loaded to failure. Specimens fixed with contoured locking plate demonstrated a higher torque to failure, angle to failure, and higher maximal torque when compared to specimens stabilized with conventional plates. Additionally, torque to failure in the locking group was independent of BMD, while those in the nonlocking group failed earlier with decreasing BMD. Similar studies by Kim et al13 and White et al38 failed to demonstrate a significant difference in torque to failure, rotation to failure, or energy to failure, between distal fibular locking plates, or nonlocking one-third tubular plates. Kim et al13 demonstrated that 2 fewer unicortical locking screws are needed to achieve the same biomechanical stability found with 3 traditional unicortical nonlocking screws and reinforced that distal fibular locked plating was independent of BMD, while nonlocking one-third tubular plating had improved performance with increasing BMD. Eckel et al9 recently performed a comparison of 4 different lateral plate constructs. The comparison included 2 separate locking plates from different manufacturers with adjunctive lag screw fixation and 2 nonlocking plates from different manufacturers. The authors found a positive correlation between increasing BMD and improved bending stiffness for all plate types. However, they found no other significant differences in plate performance with regard to torsional stiffness or fracture site rotation.
Conclusion While the focus of this article addresses surgical strategies to improve fixation of distal fibular fractures, it is important to remember that the quality of reduction remains the most critical step in treating an ankle fracture operatively. Well
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fixed yet poorly reduced fractures are associated with poor outcomes. Nevertheless, surgeons must be familiar with available fixation options as well as the potential advantages and disadvantages of each technique. Biomechanically, antiglide plating appears superior to lateral plating and locking constructs. Although locking plates may provide some mechanical advantage, they have not been shown to be clinically superior to traditional plating systems. Robust data to support the use of fibular nails are lacking, but these implants do appear to provide reliable stability with newer techniques and may prove useful in elderly patients with comminuted osteoporotic fractures or patients with substantial soft-tissue compromise. Questions remain regarding the optimal fixation of the distal fibula, especially in the setting of osteoporotic or comminuted fractures. Currently, the choice of fixation should be based on clinical judgment, patient factors, and surgeon comfort. Prospective randomized studies further comparing various forms of fixation are necessary. Authors’ Note The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Mitchell et al 26. Redfern DJ, Suave PS, Sakellariou A. Investigation of incidence of peroneal nerve injury following ankle fracture. Foot Ankle Int. 2003;24:771-774. 27. Rajeev A, Shanaka S, Sarkhell R, Kashayap NS. Functional outcomes after fibula locking nail for fragility fractures of the ankle. J Foot Ankle Surg. 2011;50:547-550. 28. Ramasamy PR, Sherry P. The role of fibular nail in the management of Weber type B ankle fractures in elderly patients with osteoporotic bone—a preliminary report. Injury. 2001;32:477-485. 29. Ryken TC, Goel VK, Clausen JD, Traynelis VC. Assessment of unicortical and bicortical fixation in a quasistatic cadaveric model: role of bone mineral density and screw torque. Spine. 1995;20:1861-1867. 30. Schaffer JJ, Manoli A. The antiglide plate for distal fibular fixation. A biomechanical comparison with fixation with a lateral plate. J Bone Joint Surg Am. 1987;69(4):596-604. 31. Schepers T, Van Lieshout EM, De Vries MR, Van der Elst M. Increased rates of wound complications with locking plates in distal fibular fractures. Injury. 2011;42: 1125-1129. 32. Stewart CM, Kiner D, Nowotarski P. Intramedullary nail fixation of fibular fractures associated with tibial shaft and pilon fractures. J Orthop Traum. 2013;5:114-117. 33. Still GP, Atwood TC. Operative outcome of 41 ankle fractures: a retrospective analysis. J Foot Ankle Surg. 2009;43(3):300-339.
34. Torneta P III, Creevy W. Lag screw only fixation of the lateral malleolus. J Orthop Traum. 2001;15(2):119-121. 35. Treadwell JR, Fallat LM. The antiglide plate for Danis-Weber type B fibula fractures: a review of 71 cases. J Foot Ankle Surg. 1993;32:573-579. 36. Tsukada S, Otsuji M, Shiozaki A, et al. Locking versus nonlocking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial. Int Orthop. 2013;37:2451-2456. 37. Weber M, Krause F. Peroneal tendon lesions caused by antiglide plates used for fixation of lateral malleolar fractures: the effect of plate and screw position. Foot Ankle Int. 2005;26(4):281. 38. White NJ, Corr DT, Wagg JP, Lorincz C, Buckley RE. Locked plate fixation of the comminuted distal fibula: a biomechanical study. Can J Surg. 2013;56:35-40. 39. Winkler B, Weber BG, Simpson LA. The dorsal antiglide plate in treatment of Danis-Weber type B fractures of the distal fibula. Clin Orthop. 1990;259:204-209. 40. Wissing JC, van Laarhoven CJ, van der Werken C. The posterior antiglide plate for fixation of fractures of the lateral malleolus. Injury. 1992;23:94-96. 41. Zahn RK, Frey S, Jakubietz RG, et al. A contoured locking plate for distal fibula fractures in osteoporotic bone: a biomechanical study. Injury. 2012;43:718-725.
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research-article2014
FAIXXX10.1177/1071100714555712Foot & Ankle InternationalMitchell et al
Topical Review
Fixation of Distal Fibula Fractures: An Update
Foot & Ankle International® 2014, Vol. 35(12) 1367–1375 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100714555712 fai.sagepub.com
Justin J. Mitchell, MD1, LCDR James R. Bailey, MD, MC, USN3, Anthony E. Bozzio, MD1, Ryan R. Fader, MD1, and Cyril Mauffrey MD, FACS, FRCS1,2 Level of Evidence: Level V, expert opinion. Keywords: trauma, outcome studies, biomechanics, tendon disorders, statistical analysis
Introduction Fractures of the fibula are common injuries treated by orthopaedic surgeons and often require surgical stabilization. Nevertheless, controversy remains with regard to the optimal method of fixation. Studies have demonstrated that anatomic reduction and fixation of the distal fibula improves outcomes in patients with an unstable ankle mortise.12,25 Traditionally, fixation involved the use of a lateral one-third tubular plate with bicortical screws proximal to the fracture site and either unicortical or bicortical screws for distal fragment fixation 2,4,12,19 However, some have cited potential disadvantages of this lateral fixation, including the possibility of intra-articular screw placement, painful hardware, inferior biomechanical strength, inadequate distal fixation, loss of fixation, and wound problems.4,5,12,15,20,21,37 In recent years, alternative methods of fixation have been proposed including posterolateral plate fixation, locking plate constructs, and the use of intramedullary devices. Since the advent of these alternative techniques, there has been continued discussion and research regarding the use of these fixation methods. As this is a potential area for continued and future research and interest, we present a review of available literature to provide an update on current fixation techniques as well as the challenges, benefits, and drawbacks of each.
Surgical Anatomy and Approaches The distal fibula may be approached using either a direct lateral or posterolateral approach. The direct lateral approach is the most commonly utilized when performing either lateral or posterior fixation. However, choice of approach is influenced by surgeon preference, fracture type and configuration, associated injuries, and status of the skin. With the direct lateral approach, exposure is relatively straightforward. Nevertheless, care must be taken to protect both the sural nerve posteriorly and the superficial peroneal nerve anteriorly. The latter usually exits the crural fascia
approximately 12 to 14 cm above the ankle before dividing in to the intermediate and medial dorsal cutaneous nerves.3 This anatomy is particularly relevant in fractures at or above the level of the syndesmosis, where the superficial peroneal nerve crosses directly in the field of dissection, placing it at risk for transection or irritation. The posterolateral approach to the distal fibula exploits the interval between the peroneal tendons and the flexor hallucis longus. With the patient in a lateral decubitus or prone position, the incision is typically placed halfway between the posterior border of the distal fibula and the lateral border of the Achilles tendon. Following skin incision, the sural nerve can be encountered and must be protected and gently retracted. The peroneal tendon sheath is incised in line with the incision. The peroneal tendons are retracted anteriorly to expose the fibula and the flexor hallucis longus muscle medially. Elevating the lateral fibers of the flexor hallucis longus provides further exposure of the fibula and the posterior tibia. Distal fibula fractures (and when necessary, a distal tibia fracture) can be debrided, reduced, and stabilized through this approach. This incision; however, is often made slightly posterior if the goal is posterior plating.
Surgical Fixation Techniques Lateral Plating A nonlocking plate has traditionally been used for direct lateral fixation of the distal fibula (Figure 1). Proponents of 1
University of Colorado Hospital, Department of Orthopaedic Surgery, Aurora, CO, USA 2 Denver Health Medical Center, Department of Orthopaedic Surgery, Denver, CO, USA 3 Naval Hospital–Bremerton, Department of Orthopaedic Surgery, Bremerton, WA, USA Corresponding Author: Cyril Mauffrey, MD, FACS, FRCS, Denver Health Medical Centre, 777 Bannock Street, Denver, CO 80204, USA. Email: [email protected]
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Foot & Ankle International 35(12) used and has demonstrated equivalency to plate fixation in young patients with good bone stock. This technique is safe and effective, with limited dissection and less prominent hardware.17,34 However, it is reserved for use in long oblique fractures and is not a viable option for individuals with comminuted fractures, osteoporosis, limited compliance with weightbearing, or irreducible syndesmotic injury.34 Various authors have reported unsatisfactory fixation and decreased fixation strength with unicortical cancellous fixation, especially in osteoporotic or comminuted bone.14,16 This can lead to loss of fixation as well as delayed or nonunion.2,4,6 While locking and posterior plating may obviate these risks, authors have attempted to provide means by which standard nonlocking constructs with adjunct fixation could be used, including the use of carefully placed bicortical screws in the distal fragment or tetracortical fixation using tibia-pro-fibula (syndesmotic) screws14,20,24 (Figure 3). Panchbhavi et al24 investigated this strategy and found that when compared with the same construct without additional screws, tetracortical fixation demonstrated a 9% increase in torque to failure, 24% increase ability to withstand external rotation, and a 34% increase in energy before failure of the construct. This fixation technique adds little operative time, is inexpensive, and is a technically straightforward method to increase the stability of the construct.24
Posterior Plating
Figure 1. Preoperative (A) anterior/posterior and (B) lateral radiographs of a displaced fibula fracture. Postoperative (C) anterior/posterior and (D) lateral views of a direct lateral plate on the fibula with the use of an interfragmentary compression screw.
direct lateral plating maintain that this construct is simple, provides sufficient biomechanical stability, and will not lead to peroneal tendon pain or irritation. Techniques have evolved over time (including the use of locked plating constructs as discussed in the following), but fixation using this plate typically calls for at least 2 bicortical screws proximal to the fracture site and 2 unicortical cancellous screws distally. There has been debate regarding the distal fixation and the use of bicortical versus unicortical screws.20,29 Proponents of the use of bicortical screws argue that this provides superior fixation to unicortical fixation with cancellous screws.15,18 Conversely, those in favor of unicortical screw placement point to the possibility of intra-articular screw placement with the use of bicortical screws.38,40 The use of an interfragmentary lag screw (Figure 1) has been employed for increased compression and stability in oblique fibular fractures.19,20 Lag screw only fixation of the long oblique fracture of the lateral malleolus has also been
In 1982 Brunner and Weber proposed the use of a posterior antiglide plate as a new method of fibular fixation. They concluded that posterior plating was advantageous as it was biomechanically superior and avoided the soft tissue complications associated with subcutaneous plate placement.6 The use of posterior plating in lieu of lateral fixation remains controversial. Advocates of posterior plate application argue that the concern for intra-articular screw penetration is voided with posterior to anterior screw placement. Other potential benefits include less dissection and operative time, minimum bending of the plate, and the fact that distal screw fixation may be unnecessary.30,35,37,39,40 Nevertheless, this technique entails dissection of the peroneals and potential irritation by the plate. Similar to lateral plating, a one-third tubular plate is typically used. At least 2 bicortical nonlocking screws are placed through the most proximal portion of the plate (Figure 2). The posterior plate and the typical orientation of the fracture line (apex postero-superior) create an axilla. The plate configuration thereby forms an antiglide construct, and although used by some surgeons, distal fragment fixation is not required.15,21,30,39,40 In fact, some authors advocate not filling the distal hole with a screw as they believe that screw head is what causes peroneal irritation with this construct.37 An interfragmentary compression screw may also be placed through the plate perpendicular to
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Figure 2. (A) Anterior/posterior and (B) lateral radiographs of a displaced fibula fracture with posterior malleolar and syndesmotic injury. (C) Demonstrates posterior plating construct for a distal fibula fracture in conjunction with posterior plate fixation of the posterior malleolar fragment and TightRope (Arthrex, Napes, FL) fixation of the syndesmosis.
the fracture in a traditional lag fashion. This requires planning when placing the plate such that an accessible screw hole is appropriately oriented. Wissing et al40 reported on the potential advantages of posterior antiglide plating in a retrospective review of their cases’ arguing that in cases of severe soft tissue injury, a lateral plate caused more skin irritation. In addition, the shape and bony structure of distal fibula is not uniform, and a lateral plate must be contoured in order to sit directly against the bone, which may result in a biomechanically disadvantaged construct. Finally, the thin lateral cortex gives rise to decreased purchase with distal laterally based screws that can penetrate the distal tibiofibular and fibulotalar joints.
Distal Fibular Locked Plating Short, oblique fractures of the distal fibula are typically amenable to fixation using the techniques described previously. However, in patients with diminished bone stock or severely comminuted fractures, obtaining adequate fixation can be challenging. Locking plates have been reported as an alternative form of fixation in these cases.13,16,21,24 Locked plating is well described and relies on the interaction between plate and screw to create a fixed angle device. The periarticular nature of the distal fibula makes distal bicortical fixation difficult. The biomechanical advantages of a fixed angle device, however, allows for the use of unicortical screws as it obviates the need for both bicortical fixation and compression between the plate and bone to stabilize the fracture.11,38,41 The locking mechanism prevents screw
toggle and back out, which may be exacerbated with the use of conventional plates in patients with deficient bone stock.41 Recently, there has been increased interest in the use of distal fibular locking plates in comminuted or osteoporotic fractures.9,11,16,28 Locking plates exist in one-third tubular form or in anatomically contoured options. These plates are typically larger and stronger with a flare at the distal aspect of the fibular metaphysis to provide multiple options for locking unicortical distal fixation. Smaller (eg, 2.7 mm) screws may be incorporated into the plate design. In addition to options for increased distal fixation, minimally invasive plate osteosynthesis with locked plating has also been used in those patients with increased risk for wound complications, infection, and high rates of complications such as the elderly and in those with diabetes or neuropathy.11,13,16,21
Intramedullary Fibular Nail Locking plates have shown promise in treating comminuted or osteoporotic fractures of the distal fibula, but potential drawbacks exist. Plate fixation may not be possible in fractures with associated soft tissue compromise or in elderly patients with fragile skin.6,10,15 There has therefore been renewed interest in the use of a retrograde screw or fibular nail for such patients (Figure 4).7,27,28,32 Retrograde nail fixation is typically performed through a small transverse incision at the distal aspect of the fibula. A guidewire is inserted in the center of the distal fibula and a reamer is used to breach the distal cortex. Closed reduction
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Figure 3. (A) Photograph of an open ankle fracture dislocation after a ground level fall in a 76-year-old female with osteoporosis and diabetes mellitus type II. (B) Anterior/posterior and (C) lateral radiographs of her immediate reduction are shown, along with (D, E) postoperatiave radiographs demonstrating tetracortical fixation in the setting of a displaced fracture of the lateral malleolus.
is used to hold the fracture in alignment, although minimally invasive reduction and adjunctive Kirschner wire fixation can also be used. Insertion of the nail follows in a retrograde fashion. Proximal and distal locking holes are available to set rotation and alignment, although this is not always performed. Proponents of this fixation cite several advantages including limited exposure, indirect closed reduction, lack of lateral plate prominence, and decreased risk of peroneal tendon irritation.7,27 There are, however, potential disadvantages associated with this strategy including the potential for suboptimal reduction or rotational malalignment. The technique
can also be technically demanding with regard to the placement of percutaneous locking screws, and surgeons that have chosen to forgo this step of the procedure have noted an increased incidence of failure and fracture instability.7
Outcomes/Literature Review Few studies have directly compared various distal fibular fixation techniques. Nevertheless, several recent investigations have examined clinical outcomes, complications, and biomechanical profiles individually.
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Figure 4. (A) Photograph of a right ankle in a 76-year-old female who fractured her distal fibula after stepping off of a curb. Anterior/ posterior radiograph of the injury is shown in (B), and anterior/posterior radiograph of fixation with a fibular nail is shown in (C). (Image courtesy of Acumed, LLC, Hillsboro, OR, Mason Miller, Representative).
Clinical Outcomes Clinical outcomes following fixation of distal fibula fractures focus on fracture union, wound healing, pain relief, restoration of motion, and ankle stability. Several studies have recently reviewed the outcomes for operatively treated ankle fractures. The efficacy of fibular fixation with a lateral plate has been well studied as it relates to union, function, and activity.4,5,10,12,18-20,24,25 Available studies that focus primarily on fixation with one-third tubular plates report that the most important prognostic factors following operative treatment include anatomic reconstruction of the articular surfaces and restoration of fibular length and alignment.2,4,6,12,19,25 Other than malreduction, negative prognostic factors include a delay in fixation greater than 4 weeks post injury, injury to ligamentous structures around the ankle, associated tarsal/ metatarsal fractures, and neuropathy or vasculopathy.5,12,14 Still and Atwood33 recently retrospectively reviewed 41 operatively treated ankle fractures using several operative techniques. Using a modification of the American College of Foot and Ankle Scoring Scale (ACFAS),8 male gender was the only independent variable that statistically increased the likelihood of a satisfactory subjective result. Obesity, smoking, sustaining a high fibular fracture, or undergoing syndesmotic repair decreased the likelihood of a satisfactory result. There have been several studies examining clinical outcomes following posterior plating. In a prospective evaluation of 32 Weber B fractures treated with posterior plating, Ostrum23 reported that 100% of fractures healed uneventfully. There were no nonunions, malunions, wound complications, loss of fixation, or intra-articular screw penetration. Four patients had transient peroneal tendon pain, and 2 patients had later plate removal for symptomatic interfragmentary screw. Twenty of 21 patients who returned a questionnaire were satisfied with their results.
In a review of 93 patients treated with posterior plating, Winkler et al39 reported 67% excellent, 28% good, and 5% poor results at 1-year follow-up. The results were better in young male patients. In another series, Treadwell and Fallat35 reported on 71 Weber B fractures in 70 patients. They reported only 1 case of premature loosening of fixation prior to fracture union and 2 cases of peroneal tendinitis related to the distal positioning of the plate. The symptoms of the latter patients resolved with plate removal. Lamontagne et al15 retrospectively reviewed the outcomes of a lateral plate construct compared to antiglide plating in 193 patients with isolated displaced lateral fibula fractures. There was 1 case of lost fixation in a noncompliant patient in the antiglide group. Otherwise, there were no nonunions or malunions reported and the authors found no statistical significance in terms of operative time, tourniquet time, duration of hospital stay, wound healing complications, or hardware removal rates. They concluded that despite some biomechanical evidence suggesting superiority of antiglide fixation, no statistical difference was seen in clinical outcomes.22 There are few clinical outcome studies specifically evaluating locked plating for distal fibula fractures. Tsukada et al36 performed a randomized controlled trial of 57 patients randomized to either locking plate fixation or nonlocking fixation. No statistically significant difference was observed in the radiographic rate of bone union, SF-36 score, or time to resolution of tenderness at the fracture site.36 Studies regarding outcomes following the use of fibular nails are limited. Appleton et al1 reviewed 37 patients who underwent fixation of unstable ankle fractures with lateral talar shift using a fibular nail. All patients were over the age of 60 years with poor bone quality and/or had significant medical comorbidity or soft tissue trauma that was not amenable to standard fixation. Average follow-up was 58 weeks, and the average Olerud and Molander Score (OMS)
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at final follow-up was 87 out of 100. Average ankle dorsiflexion at final follow-up was within 4 degrees of the uninjured ankle and plantar flexion was within 3 degrees. More than 85% of patients regained ankle motion to within 90% of the uninjured side. Radiographically, all but 1 patient had normal medial clear space and talocrural angle measurements. Another retrospective review of 24 patients with displaced fragility fractures of the distal fibula treated with fibular nail yielded good function and patient satisfaction at 1 year.27 All patients had initial displacement of the fracture with loss of the lateral buttress and went on to fracture union at an average of 8.7 weeks with no wound complications, deep infection, or deep venous thrombosis. Additionally, in their study of 11 patients treated with fibula nailing in elderly osteoporotic patients, Ramasamy and Sherry28 reported excellent results and no wound complications in 88% of cases. In the largest series to date, Bugler et al7 examined the results for 105 patients treated with fibular nail for unstable ankle fractures. Anatomical reduction was achieved in 96% of patients, while 46% had a good outcome, 40% had a fair outcome, and 14% had a poor outcome using OMS. Of note, however, reliability of these results may not be adequate as various configurations of locking screws were used throughout the study process. The initial constructs consisted of distal locking screws with a proximal blocking screw to prevent proximal migration, distal locking screws alone, a syndesmotic screw alone, or no fixation. In this first subset of patients, nail fixation without locking screws achieved rotational and longitudinal stability in only 66% of cases, while those with locking screws demonstrated greater than 90% stability. These results led to a change in technique, which included syndesmotic fixation in addition to a distal locking screw. The current recommended technique calls for antero-posterior distal locking screw to stabilize the distal fragment and allow for rotation and anatomic reduction prior to the insertion of a transverse syndesmotic screw above the fracture, which locks the nail in place.
Soft Tissue Complications Soft tissue complications and painful hardware are cited as the main indications for hardware removal in the postoperative period.5,15,25,31,33,36,37,39 Brown et al5 examined the incidence of soft tissue complications in patients who underwent open reduction and internal fixation of a short oblique fibula fracture with a lateral plate. The authors utilized the Short Form-36 (SF-36) Survey and the Short Musculoskeletal Functional Assessment (SMFA) to obtain patient information and to compare results. Thirty-one percent of patients reported pain overlying their lateral hardware. In general, the SF-36 and SMFA scores at final follow-up were significantly lower for patients who had
pain overlying their lateral hardware than for those who had no pain. Twenty-three percent either had their hardware removed or desired to have it removed. However, only 50% of those who underwent hardware removal had improvement in their lateral ankle pain. To this end, no significant difference was noted in SMFA or SF-36 scores between patients who had their lateral hardware removed and those who had not. These results suggest that the lateral implant may play less of a role in the sensation of pain than other authors have suggested and could be related to cutaneous neuralgia from the incision, concomitant soft tissue injury, or loss of motion related to tibiotalar joint stiffness. With regard to posterior antiglide plating, Winkler et al39 reported that 42 of 93 plates (45%) were removed by 1 year following surgery. The authors did not expand as to why the plates were removed. In that retrospective series reported by Lamontagne et al15 comparing lateral and posterior antiglide fixation of the distal fibula. The authors found a trend toward increased incidence of hardware removal (17% vs 13%), discomfort (12% vs 7%), and wound dehiscence or infection (4% vs 1%) for lateral plate fixation when compared to a posterior antiglide plate, although these differences were not statistically significant. Moreover, they found no statistically significant difference in operative time, tourniquet time, or length of hospital stay. Weber and Krause37 performed a retrospective review of 70 patients treated with posterior antiglide plating in an attempt to identify the location of peroneal tendon lesions as they relate to plate position and how this relates to the need for later hardware removal. In addition to this, they performed dissection of the retromalleolar space in 10 cadavers to study the anatomic variability of the peroneal groove. The plate was removed in 30 patients (43%) because of discomfort and/or physical exam findings suggestive of peroneal irritation. They noted that peroneal tendon lesions were identified in only 9 of the 30 patients (30%) at the time of hardware removal. Two of these 9 patients had peroneal symptoms preoperatively, while the remaining patients had their plates removed at the physician’s suggestion based on physical exam. The authors found that plate position did not correlate with peroneal tendon lesions but rather that placement of a prominent or oblique screw in the most distal hole of the plate did. In cadaveric dissection, the shape of the peroneal groove was uniform and did not contribute to peroneal lesions or irritation. Based on these findings, they recommended not filling the most distal hole of the plate. With regard to locked plating, Schepers et al31 conducted a retrospective clinical study of 205 patients evaluating the complication rates in fixation of the distal fibula using a locking plate compared with those procedures using the nonlocking plate. Of the 40 patients who underwent fixation with locked plating, 7 had wound complications; and of the 165 patients treated with the nonlocking plate, 9 had wound complications. The rate of wound complications
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Mitchell et al observed with the use of the locking plate was significantly higher than that with the nonlocking plate. Meanwhile, Tsukada et al36 did not find any differences in wound complications when comparing locking and nonlocking plates and further did not report any instances of plate removal at 1-year follow-up. These studies differed in that Tsukada’s group used anatomically precontoured locking plates while Schepers et al did not. The data on complications associated with fibular nail fixation are limited. In the previously referenced series by Bulger et al,7 a small subset of all patients (5%) underwent revision surgery for failure of fixation. However, as previously noted, surgical technique changed over time, and early fixation modalities were without locking screws. In this initial subset, 78% of patients experienced no complication. However, 5 patients developed a postoperative infection, and 7 patients failed by loss of fixation. Five of these required revision surgery. With the advent of the new fixation method that included the use of a syndesmotic screw, there was only 1 failure of fixation, and this occurred in a patient that was noncompliant with postoperative weightbearing precautions. Five (5%) patients had postoperative wound infection and 16 patients (15%) underwent hardware removal.
Biomechanics In an attempt to answer the question of biomechanical superiority, Shaffer and Manoli30 performed a cadaveric study comparing the strength of traditional lateral plating with posterior antiglide plating of the distal fibula. Short oblique fractures were created in 24 fresh-frozen cadaveric lower extremities. The extremities were then statically and axially loaded using a biaxial electrohydraulic testing system following reduction and fixation with either a lateral or posterior antiglide plate. Ten fibulae were fixed with a contoured one-third tubular plate without lag screw fixation. Fourteen fibulae were fixed with posterior one-third tubular antiglide plate. Two bicortical 3.5 mm screws were used in the proximal fragment without distal fixation. All specimens were loaded to failure using a supination external rotation force. The last 10 consecutive specimens in the antiglide plate group were retested after being replated with new screw holes and a supplemental lag screw placed through the plate. Fibulae fixed with antiglide plates had a significantly higher failure torque when compared to those fixed with lateral plates. Antiglide plates also demonstrated significantly higher stiffness and energy absorbed before failure (364 Newton meter degrees vs 290 Newton meter degrees). The authors were unable to demonstrate a significant difference between the antiglide plate group and the antiglide plate plus lag screw group. Minihane et al21 subsequently performed a biomechanical comparison between posterior antiglide and lateral
locking plate fixation for displaced short oblique fractures of fibula in osteoporotic bones. Fixation of 18 fresh frozen ankles paired by bone mineral density (BMD) following DEXA scan was performed. Simulated SER IV fractures were created. Nine fractures were stabilized with a lateral one-third tubular locking plate with an independent lag screw while 9 were stabilized with a nonlocking posterolateral antiglide plate augmented with a lag screw through the plate. Significantly higher (P = .01) torque to failure and significantly higher (P = .005) construct stiffness was identified in bones fixed with posterior plates. No differences in angular rotation at failure were identified. Other authors have reviewed biomechanical differences of fibulae fixed with locked plating compared to those fixed with one-third tubular plates.11,13,38,41 Zahn et al41 performed a biomechanical study of 10 cadaveric specimens that underwent open reduction, internal fixation (ORIF) following simulated rotational fibula fractures at the level of the syndesmosis. Five underwent contoured traditional nonlocking fixation while 5 others were stabilized with contoured lateral locking plates. The specimens were then torsionally loaded to failure. Specimens fixed with contoured locking plate demonstrated a higher torque to failure, angle to failure, and higher maximal torque when compared to specimens stabilized with conventional plates. Additionally, torque to failure in the locking group was independent of BMD, while those in the nonlocking group failed earlier with decreasing BMD. Similar studies by Kim et al13 and White et al38 failed to demonstrate a significant difference in torque to failure, rotation to failure, or energy to failure, between distal fibular locking plates, or nonlocking one-third tubular plates. Kim et al13 demonstrated that 2 fewer unicortical locking screws are needed to achieve the same biomechanical stability found with 3 traditional unicortical nonlocking screws and reinforced that distal fibular locked plating was independent of BMD, while nonlocking one-third tubular plating had improved performance with increasing BMD. Eckel et al9 recently performed a comparison of 4 different lateral plate constructs. The comparison included 2 separate locking plates from different manufacturers with adjunctive lag screw fixation and 2 nonlocking plates from different manufacturers. The authors found a positive correlation between increasing BMD and improved bending stiffness for all plate types. However, they found no other significant differences in plate performance with regard to torsional stiffness or fracture site rotation.
Conclusion While the focus of this article addresses surgical strategies to improve fixation of distal fibular fractures, it is important to remember that the quality of reduction remains the most critical step in treating an ankle fracture operatively. Well
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fixed yet poorly reduced fractures are associated with poor outcomes. Nevertheless, surgeons must be familiar with available fixation options as well as the potential advantages and disadvantages of each technique. Biomechanically, antiglide plating appears superior to lateral plating and locking constructs. Although locking plates may provide some mechanical advantage, they have not been shown to be clinically superior to traditional plating systems. Robust data to support the use of fibular nails are lacking, but these implants do appear to provide reliable stability with newer techniques and may prove useful in elderly patients with comminuted osteoporotic fractures or patients with substantial soft-tissue compromise. Questions remain regarding the optimal fixation of the distal fibula, especially in the setting of osteoporotic or comminuted fractures. Currently, the choice of fixation should be based on clinical judgment, patient factors, and surgeon comfort. Prospective randomized studies further comparing various forms of fixation are necessary. Authors’ Note The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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