Intramedullary Nail Fixation of the Fibula as a Treatment Alternative of Ankle Fractures in a High Risk Patient Population M. Christian Moody, MD Brian Weatherby, MD Greenville Health System Steadman-Hawkins Clinic of the Carolinas Greenville, SC
Disclosure No Conflict to Disclose Intramedullary Nail Fixation of the Fibula as a Treatment Alternative of Ankle Fractures in a High Risk Patient Population M. Christian Moody, MD Brian Weatherby, MD Our disclosures are in the Final AOFAS Mobile App. We have no potential conflicts with this presentation.
Purpose To identify high risk patients with multiple comorbidities who underwent fixation of unstable ankle fractures using an intramedullary fibular nail implant and present the clinical outcomes, complications, and Olerud and Molander scores.
Methods Retrospective review - High risk patients with fibular IMN - January 2011 and June 2015 All surgeries were at the same institution by the senior author Attempts were made to contact all patients Olerud and Molander Score Satisfaction questionnaire
High Risk Uncontrolled Diabetes Neuropathy Peripheral Vascular Disease Alcoholic abuse Drug abuse Drugs impairing wound healing (steroids, biologics, chemo) Non-compliant patients (mental illness, incarceration) Poor skin quality Excessive soft tissue edema
Results 22 high risk patients with 23 ankle fractures were included Average age (range) 64.3 years (41-82) Male / Female 11/11 Average tourniquet time (range) 35.6 minutes (0-72) Average operative time (range) 49.5 minutes (25-70) Average time until WBAT (range) 6.0 weeks (0-30) Average follow-up (range) 5.7 months (2-30) Fracture Pattern 18 bimalleolar/ 5 trimalleolar
Results All fractures went on to heal with radiographic evidence of bony union 4 patients non-compliant Began weight bearing immediately postoperatively 1 patient with a severe medial fracture blister pre-dating surgery required skin grafting and had delayed weightbearing due to skin healing (30 weeks)
Complications No surgical site infections, wound complications or non unions 2 patients required return to the OR for symptomatic screw removal 1 syndesmotic screw backed out, 1 distal AP screw Both patients non-compliant with weight bearing restrictions All nails were retained at last follow-up
Questionnaire 14 of the 22 patients were reached for participation Average time from follow up to questionnaire: 24.8 months (8-35) Average Olerud and Molander score: 77.9 (40-100) Satisfaction survey 64% very satisfied 29% satisfied 7% somewhat satisfied
Conclusion The intramedullary fibular nail construct is viable alternative method of fixation that allows for protection of soft tissue, stable fracture fixation and satisfactory outcomes in the high risk patient population. Further Level 1 research is needed to determine the long term outcomes of intramedullary fibular nails compared to plate and screw fixation.
References 1. Appleton P, McQueen M, Court Brown C. The fibula nail for treatment of ankle fracture in elderly and high risk patients. Tech Foot Ankle. 2006;5(3): 204-208. 2. Asloum Y, Bedin B, Roger T, et al. Internal fixation of the fibula in ankle fractures. A prospective, randomized and comparative study: Plating versus nailing. Orthop Traumatol Surg Res. 2014;100(4Suppl):S255-259. doi:10.1016/j.otsr.2014.03.005. 3. Ashman BD, Kong C et al. Fluoroscopy-guided reduction and fibular nail fixation to manage unstable ankle fractures in patients with diabetes. Bone Joint J 2016; 98-B: 1197-1201. 4. Bugler KE, Watson CD, Hardie AR, et al. The treatment of unstable fractures of the ankle using the Acumed fibular nail: Development of a technique. J Bone Joint Surg Br. 2012;94- B(8):1107-1112. doi:10.1302/0301-620x.94b8.28620. 5. Bugler KE, Watson CD, Hardie AR, et al. The Acumed fibular nail in compromised patients with unstable ankle fractures. Bone Joint J. 2013Feb;95-B (Supp 5)5. 6. Daly PJ, Fitzgerald RH, Melton LJ, et al. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand. 1987;58(5):539-544. doi:10.3109/17453678709146395. 7. Gehr J, Neber W, et al. New concepts in the treatment of ankle joint fractures, the IP-XS and IP-XXS nail in the treatment of ankle joint fractures. Arch Orthop Trauma Surg. 2004;1(24):96-103. 8. Jain S, Haughton B, et al. Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes. J Orthopaed Traumatol 2014; 15:245-54. 9. Lamontagne J, Blachut P, Broekhuyse HM, et al. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002;16(7):498-502. doi:10.1097/00005131-200208000-00008. 10. McCormack R, Leith J. Ankle fractures in diabetics, complications of surgical management. JBJS [Br] 1998:80-B:689-92. 11. Mak KH, Chan KM, Leung PC. Ankle fracture treated with the AO principle-an experience with 116 cases. Injury. 1985;16(4):265-272. doi:10.1016/s0020-1383(85)80017-6. 12. Miller AG, Margules A, Raikin SM. Risk factors for wound complications after ankle fracture surgery. J Bone Joint Surg Am. 2012;94(22):2047-2052. doi:10.2106/jbjs.k.01088. 13. Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch Orthop Trauma Surg. 1984;103(3):190-194. doi:10.1007/bf00435553. 14. Ovaska MT, Mäkinen TJ, Madanat R, et al. Risk factors for deep surgical site infection following operative treatment of ankle fractures. J Bone Joint Surg Am. 2013;95(4):348-353. doi:10.2106/jbjs.k.01672. 15. Rajeev A, Shanaka S, et al. Functional outcomes after fibula locking nail for fragility fractures of the ankle. J Foot Ankle Surg. 2011;50:547-550. 16. Ramasamy PR, Sherry P. The role of a fibular nail in the management of Weber type B ankle fractures in elderly patients with osteoporotic bone - A preliminary report. Injury. 2001;32(6):477-485. doi:10.1016/s0020-1383(01)00030-4. 17. Schepers T et al. Increased rates of wound complications with locked plates in distal fibular fractures. Injury 2011; 42:1125-9. 18. Switaj et al. A biomechanical comparison study of a modern fibular nail and distal fibular locking plate in AO/OTA 44C2 ankle fractures. Journal of Orthopaedic Surgery and Research. 2016 11:1000. 19. Stewart C, Kiner D, Nowotarski P. Intramedullary nail fixation of fibula fractures associated with tibial shaft and pilon fractures. J Orthop Trauma. 2013;27:e114-117. 20. Tawari G, Kakwani R, Shankar K. Ankle fracture fixation- plate osteo-synthesis versus intramedullary fibular nail. Orthop Proceed. 2012;94(B):SUPP XXXIX 239. 21. Walton DM, Adams SB, Parekh SG. Intramedullary fixation for fractures of the distal fibula. Foot Ankle Int. 2016;37(1):115-123. 22. White T, Bugler K, Appleton P, et al. A Prospective, Randomized Controlled Trial of a Fibular Nail Versus Standard Open Reduction and Internal Fixation for Fixation of Ankle Fractures in Elderly Patients. Bone Joint J 2016; 98-B: 1248-52. 23. White T, Bugler K. How I fix ankle fractures in diabetic patients. J Trauma Orthop. 2015;3(1):56-57. 24. Wukich DK, Crim BE, Frykberg RG, Rosario BL. Neuropathy and poorly controlled diabetes increase the rate of surgical site infection after foot and ankle surgery. J Bone Joint Surg Am. 2014;96(10):832-839. doi:10.2106/jbjs.l.01302. 25. Anderson, SA, Li, X, et al. Ankle Fractures in the Elderly: Initial and Long-term Outcomes. Foot Ankle Int. 2008;29(12):1184-1888. 26. Wukich DK, Joseph A, et al. Outcomes of Ankle Fractures in Patients with Uncomplicated versus Complicated Diabetes. Foot Ankle Int. 2011;23(2):120-130. 27. Costigan W, Thordarson DB, et al. Operative Management of Ankle Fractures in Patients with Diabetes Mellitus. Foot Ankle Int. 2007;28(1):32-37.