Fibular Fixation Research Articles

Pilon Fractures: Challenges and Solutions.

Pilon fractures include a wide range of complexity. The timing and type of definitive fixation is dictated by the soft tissue injury and energy imparted to the fracture. One should have a low threshold for staged protocols and delayed definitive fixation to avoid complications. Proper radiographs and advanced imaging should be obtained for an exacting diagnosis and preoperative planning. Diligent management of the soft tissue and anatomic restoration of the articular surface, length, rotation, and axial alignment with stable fixation to the diaphysis should be obtained once feasible. Intramedullary implants with percutaneous articular fixation for simple or extra-articular patterns provide good results with little soft tissue insult in the zone of injury. Minimally invasive plate osteosynthesis techniques can help mitigate some concerns with soft tissue compromise while obtaining good articular alignment. Locking or conventional plating with lag screw fixation is used for complex articular injuries with or without fibular fixation. External fixators are generally used for temporizing measures but can be utilized as definitive fixation when indicated. There is a role for acute fusion in severely comminuted, osteoporotic, or arthritic fractures in patients with poor healing potential. This article outlines the diagnostic workup and treatment of these vexing injuries with solutions to challenges that arise.

Evaluation of Results of Combined Blocking Screw and Interlocking Intramedullary Nail in the Treatment of Diaphyseo-Metaphyseal Tibial Fractures

AbstractBackground: Diaphyseo-metaphyseal tibial fractures tend to malalign while treatment by interlocking intramedullary nail. Multiple techniques are used to avoid malalignment as provisional unicortical plate, percutaneous clamping, universal distractor, fibular plating in distal tibia and blocking screw.Aim of Study: Was to evaluate the results of combined blocking screw and interlocking intramedullary nail in the treatment of diaphyseo-metaphyseal tibial fractures.Patients and Methods: This study was done on 21 patients with closed proximal or distal diaphyseo-metaphyseal tibial fractures, admitted at Tanta University Hospital. The distri-bution of patients was according to age, sex, and side, mode of trauma, and AO type of fracture, medical history, smoking, fracture level, time lag, fibular fixation and design of inter-locking nail. Fixation was done by interlocking intramedullary nail and the reduction was assisted by blocking screw in the coronal plane for varus or valgus malalignment and in the sagittal plane for recurvatum or procurvatum malalignment. Clinical evaluation was according to Hospital of Special Surgery Knee Rating Scale.Results: There were significant statistical correlation between the final clinical result and interlocking nail design either conventional or expert tibial nail or the time for union. There were significant statistical correlation between the time of union and sex of patients, mode of trauma, type of fracture, fibular fracture fixation and smoking.Conclusion: Blocking screw is a simple technique that assist in the reduction of diaphyseo-metaphyseal tibial fractures while fixation by interlocking nail, maintenance of the reduc-tion and stability of the fracture.

Functional outcome of the effect of fibular fixation on malaligned fractures of lower third tibia-fibula treated by interlocking nail of the tibia

Background & Objectives: In the treatment of fractures of the distal third of the tibia and fibula treated by interlocking nailing of the tibia, the role of fixing the fibular fracture is not clearly defined. This study was undertaken to assess the benefits of fixation of the fibula clinically, radio graphically and functionally in fractures of the lower third of the leg.Methods: 18 patients with fractures of the lower third of the leg were followed up for an average of fourteen months. The patients were divided in to two groups based on whether fibula was fixed or not, the fracture tibia being treated with interlocking intramedullary nailing in all the cases. In the follow up the two groups were compared for radiological differences in the angulation at the fracture site, clinical and functional outcome at the end of six months, time of union and complications.Results: The demographics of the two groups were similar with respect to age, sex, side of fracture, fracture classification and nature of the injury. The average valgus angulation was significantly less in the group where fibula was fixed (p=0.009). The outcome of the two groups for clinical ankle score, measured at six months follow up, time of union and complications showed no significant differences.Interpretation & Conclusion: Fixation of the fibula decreases the malalignment of the tibia in distal third fractures of the tibia and fibula treated with interlocking nailing of the tibia.

Role of fibular fixation in static intramedullary interlocking nailing for distal third tibia and fibula fracture

Treatment of distal third tibia and fibula fractures remains a challenge classically being treated with standard plating, but intramedullary nailing has gained popularity. As there is a mismatch between the diameters of the nail and the medullary canal, with no nail-cortex contact, the nail may translate laterally along coronally placed locking screws and increased stress in placed on the locking holes to maintain fracture alignment after surgery. Various techniques have been recommended to improve nailing in these fractures including fibular plating (distal third fractures), temporary unicortical plating, different nail design with different proximal bends (proximal third fractures) and blocking screws (poller screws). The aim of the study is to evaluate the clinical use of fibular plating as a supplement to stability in addition to intramedullary nailing in distal both bone fractures of leg. Methods: A prospective study of 20 cases of distal third tibia fibula fractures treated with statically locked intra medullary nailing with supplementary fibular plating between March 2017 and September 2018 at RIMS, Ranchi. All the fractures were followed through till union of fracture with clinical and radiological examination at intervals of 4 to 6 weeks. On follow up axial alignment was assessed and functional analysis was quantified using Karlstorm – Olerud score. Complications were divided into those which were related to fibular plate and those which were not. Results: All the fractures eventually united in a mean period of 12.8 weeks. Karlstrom-Olerud score was excellent in 12 fractures (60%), good in 5 patients (25%) and fair in 2 patients (10%) and poor in 1 patient (5%).The alignment was maintained in coronal plane till union with the mean remaining the same i.e 1.6 degrees. The mean sagital plane alignment at the time of union was 0.4 degrees, the loss of alignment was not statistically significant. The fibular plate related complications were encountered in two cases where we had skin necrosis and deep infection, which needed aggressive antibiotic therapy and those patients were also given cast support for twelve weeks. Conclusion: Fibular plating, when supplemented the intramedullary nailing of distal third tibia fibula fractures, were effective in achieving the fracture alignment especially in fresh fractures, Improves not only angular stability but also rotational stability, Maintained the fracture alignment till union and prevents loss of initial reduction.

Techniques and Considerations for the Operative Treatment of Ankle Fractures in the Elderly.

* In managing fragility fractures about the ankle, nonoperative treatment should be considered with the caveat that soft-tissue integrity is of the utmost importance.* Consultation with medical and nutritional services for the comanagement of elderly patients with a fragility ankle fracture improves outcomes.* Soft-tissue preservation in the elderly is optimized with the judicious use of a tourniquet.* In elderly patients, a congruent ankle joint with axial alignment and stability should be emphasized over achieving anatomic articular reduction.* Less invasive surgical techniques, such as percutaneously placed anterior-to-posterior screws for posterior malleolar fractures and intramedullary fibular fixation, should be considered in the elderly.* Construct stability in elderly patients is maximized with the use of lateral locking plates, tibia-pro-fibula screws, and bicortical medial malleolar screws.* The use of external fixation with hydroxyapatite-coated pins should be considered in the treatment algorithm for fragility ankle fractures in elderly patients.

Kirschner wire combined with external fixator for open comminuted distal tibiofibular fractures according to the concept of damage control orthopaedics

Objective To report the clinical efficacy of Kirschner wire combined with external fixator in the treatment of open comminuted distal tibiofibular fractures according to the concept of damage control orthopaedics. Methods A case series study was done on the clinical data of 15 open comminuted distal tibiofibular fractures which had been treated with kirschner wire combined with external fixation from January 2015 to August 2018 at Department of Orthopedics, Affiliated Hospital to Logistics College of Chinese People's Armed Police. They were 12 men and 3 women, aged from 27 to 62 years (mean, 46.5 years). By the Gustilo classification, there were one case of type Ⅰ, 4 cases of type Ⅱ, 7 cases of type ⅢA, 2 cases of type ⅢB and one case of type ⅢC. All the patients were treated with emergency debridement, tibial fixation using external fixator and fibular fixation using kirschner wire, followed by vacuum sealing drainage(VSD). Effective anti-inflammatory and other comprehensive treatments were given postoperatively. Regular follow-up was conducted to observe fracture healing and complications like osteomyelitis and bone disconnection. At the final follow-up, the American Orthopaedic Foot Ankle Society (AOFAS) ankle-hindfoot scale was used to evaluate the ankle function. Results All the patients were followed up for 12 to 18 months (mean, 12.8 months). Primary bone union was achieved in 13 cases (86.7%), delayed healing observed in one case (6.7%) and bone nonunion in one case (6.7%). No osteomyelitis occurred. By the AOFAS ankle-hindfoot scale, the ankle function was rated as excellent in 9 cases, as good in 4, as fair in one and as poor in one. Conclusions For patients with open comminuted distal tibiofibular fracture, treatment should be conducted according to the concept of damage control orthopaedics. After early thorough debridement, the tibia should be fixated using external fixator and the fibula using kirschner wire, followed by VSD, leading to economical cost and satisfactory clinical efficacy. Key words: Tibial fractures; Fibular fractures; External fixators; Bone nail; Damage control orthopaedics

Outcomes Following Posterior and Posterolateral Plating of Distal Fibula Fractures.

Ankle fractures are common orthopaedic injuries often requiring open reduction and internal fixation. A variety of positions for plate placement exist for surgical fixation of distal fibula fractures, including direct lateral, posterior, or posterolateral. Direct lateral is more common, despite evidence that posterior and posterolateral placement is mechanically superior. However, concern for peroneal tendon injury from posterior plating remains. Our study investigates clinical and functional outcomes of patients who underwent operative fixation of distal fibula fractures with posterior or posterolateral plating over a 3-year period. Analyses were performed on 59 patients with at least 2 years of follow-up. Questionnaires were used to obtain demographic data, in addition to information regarding the presence of ankle pain, subsequent hardware removal, and Foot and Ankle Outcome Scores (FAOS). In patients with at least 2 years of follow-up (average 39.6 ± 10.6 months), 37.2% reported ongoing ankle pain; 11 patients underwent hardware removal (18.6%), with 8 patients undergoing removal because of hardware-related pain (13.6%). FAOS scores (n = 51) were as follows: pain (79.9 ± 22.3), activities of daily living (84.2 ± 22.6), symptoms (75.7 ± 23.5), sports (69.4 ± 31.6), and quality of life (58.3 ± 30.5). Posterior and posterolateral plating achieved good clinical and high functional outcomes across our study population. The percentage of hardware removal in our study was either equivalent to, or less than, historical controls for any type of fibular fixation, and removal may be helpful for those patients whose postoperative ankle pain is subjectively related to the hardware. Levels of Evidence: Therapeutic, Level IV: Retrospective.

New “Freer test” for assessment of syndesmotic diastasis -Cadaveric study

Category: Sports Introduction/Purpose: Syndesmotic stability is usually assessed arthroscopically by an arthroscopic probe insertion between the anterolateral tibio-fibular recess. This probe test can predict the syndesmotic instability, however, is difficult to determine syndesmotic fixation. The syndesmosis has dynamic motion and fairly firm structure, 2 mm thin probe cannot make syndesmotic dynamic diastasis. We proposed a new “Freer test” for diagnosis of syndesmosis injury which performed to insert a 2 mm diameter freer elevator between tibio-fibular lateral gutter while keeping the ankle at the plantigrade. The purpose of the present study was to evaluate the diagnostic value of freer test for anterior inferior tibiofibular ligament (AITFL) complete tear, interosseous ligament (IOL) tear and Weber type B fibular fracture. Methods: Ten fresh ankle cadaveric specimens were used. Operative procedures progressed as below; firstly, exposed antero-lateral ankle joint with direct lateral longitudinal incision, incised AITFL, incised IOL, performed Weber type B osteotomy at fibular, fixed the osteomized fibular with 8-hole locking plate and fixed the AITFL with suture anchors. In each procedure, freer tests with ankle dorsiflexion (DF, plantigrade) and plantarflexion (PF) were performed with freer elevator linked 3 kgf compression gauge. A negative test was defined as the freer did not insert with a more than 3 kgf. A positive test was defined lesser than 3 kgf, and measured the force at the insertion. Results: All freer test was negative with DF before procedures. Six ankles with PF were positive with average 1.5 kgf. All freer test positive has shown after AITFL cutting in DF, PF(mean 1.76 kgf, 1.19 kgf). After IOL cutting, all freer tests were positive in DF, PF(mean 1.46, 0.79 kgf). After fibular osteotomy, all freer tests were positive in DF, PF (mean 0.83,0.18 kgf). After fibular fixation with plate, all freer tests were positive in DF, PF (mean 1.26, 0.97 kgf). After syndesmotic fixation with anchors, 8 freer tests were positive in DF. 2 negative in PF, 4 negative in PF and 6 positive in PF. 2 positive in DF had partial breakage on anchor footprint due to weak bone. Conclusion: The “freer test” is useful diagnostic tool which test positive means AITFL rupture.

An Accuracy of Syndesmotic Reduction by Direct Visualization Technique

Category: Trauma Introduction/Purpose: Syndesmotic injury is commonly seen associated with acute ankle fracture. Syndesmotic malreduction was proven be a poor prognostic factor. Many methods have been purposed to assess the quality of reduction such as direct visualization, comparing radiographic parameters to contralateral ankle fluoroscopy, and intra-operative computed tomography. In this study, we demonstrated syndesmotic malreduction rate using bilateral CT after using direct visualization technique for syndesmotic fixation. Methods: A prospective case series of 34 patients (13 left and 21 right sides) with an average age of 42 years who had rotational ankle fractures with syndesmotic injury confirmed by arthroscopic examination. All patients were treated with an open reduction and internal fixation of distal fibula using either 1/3 tubular plate or distal anatomical locking plate. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. Before syndesmotic fixation, syndesmotic reduction is made by using a large point reduction clamp and quality of the reduction was checked by direct visualization at anterior tibiofibular line. The accuracy of syndesmotic reduction is then evaluated by post-operative bilateral CT. A widening of distance between anterior tibia and fibular at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis. Results: The accuracy of syndesmotic reduction was 97.1 percent (33/34) compare to contralateral ankle. An average of BMI was 27.2 and an average of operative time was 98.2 minutes. One malreduction, was diagnosed on the criteria of a 2 mm difference from the contralateral side occurred due to a small fragment interposition at the syndemosis. This patient underwent revision surgery to remove the fragment and then fixation of syndesmosis with same manner to achieve anatomical reduction. In all cases, the screws are removed at 12 weeks. Neither breakage nor migration of screws is observed and no wound or nerve complications following this technique. Conclusion: A syndesmotic fixation using direct visualization technique demonstrate lower rate of malreduction as demonstrated by poster-operative bilateral CT scan and no complications. This technique is effective, safe, and should be considered for treatment of syndesmotic injury associated ankle fracture.

The Influence of Obesity on Ankle Fracture Treatment

Category: Ankle Introduction/Purpose: Obesity is a public health concern in the United States, with an overall prevalence of greater than one-third. From a surgical perspective, obesity may increase risk for postoperative complications, including delayed wound healing, infection or compromise of fixation/repair constructs. The purpose of this study was to retrospectively review outcomes data from the American College of Surgeons: National Surgical Quality Improvement Program (NSQIP) to delineate the impact that obesity has on operative treatment of ankle fractures. Methods: Perioperative data was collected from patients undergoing operative intervention for distal fibular or bimalleolar ankle injuries. Patients were identified from the 2006-2015 NSQIP database using current procedural terminology (CPT) codes. Obese (body mass index>30 kg/m2) and non-obese (body mass index<30 kg/m2) cohorts were identified to elucidate the influence of obesity on perioperative /postoperative complications after undergoing operative treatment for distal fibular or bimalleolar ankle injuries. Univariate and multivariate logistic regression models were created to identify independent risk factors for complications. Results: Our study identified a total of 8,377 patients including, 4,357 undergoing surgical bimalleolar ankle fracture repair and 4,020 patients undergoing surgical repair of distal fibular ankle fracture. Obese patients undergoing surgical repair of either distal fibular or bimalleolar ankle fractures were more likely to have a longer length of hospital stay (p < 0.05). Patients undergoing distal fibular fixation were found have a longer operative time. Analysis using logistic regression demonstrated no significant association obesity and DVT/sepsis (bimalleolar ankle fracture fixation) and re-operation/deep incisional SSI/wound complication/UTI (distal fibular ankle fracture fixation) Obesity was not determined to be associated with postoperative complications following distal fibular nor bimalleolar ankle fracture repair. ankle fracture repair. Conclusion: This study demonstrated that, after adjusting for potential confounders, obesity is not significantly associated with adverse outcomes following bimalleolar or distal fibular ankle fracture repair. Further analysis demonstrated that operative time and length of stay are lengthened in ankle fracture fixation in obese patients.

Clinical study of ankle fractures and role of fibula fixation

The objective of this study was to classify the different clinical scenarios in ankle fractures, looking at their mechanism of injury, relevant to the mode of treatment and to determine the functional outcome and role of fixation of the fibula. Out of forty patients treated, overall good to excellent results were obtained in 36 patients. The results were fair and poor in two patients each. There were no intraoperative complications. The only postoperative complication seen was superficial skin infection in eight patients.

Anatomic Feasibility of Distal Fibula Bicortical Screw Fixation With Lateral Neutralization Plating for Rotational Ankle Fractures

A common technique for fixation of rotational fibular fractures is to use an interfragmentary compression screw with a laterally positioned neutralization plate. The objective of the present investigation was to examine the anatomic feasibility of distal fibula bicortical fixation within this plating technique. A specific screw insertion technique was performed through a laterally positioned one-third tubular plate on a consecutive series of 81 intact cadaveric ankle mortises. The most distal plate hole was drilled, aimed 10° posterior to the midline of the fibula. The second-most distal plate hole was drilled, aimed 25° superiorly. The specimens were then dissected, and the screw termini were physically examined for whether they had penetrated the articular cartilage of the ankle mortise. The length of the most distal bicortical screw measured a mean ± standard deviation of 20.44 ± 2.49 (range 14 to 26) mm, with an extra-articular terminus in 95.06% of specimens. The length of the second-most distal bicortical screw measured a mean ± standard deviation of 19.68 ± 3.02 (range 12 to 28) mm, with an extra-articular terminus in 100% of the specimens. The results of the present study provide evidence that bicortical distal fibular fixation in accordance with basic fixation principles is anatomically possible and feasible with a one-third tubular plate. This could potentially obviate the need for more expensive fixation options (i.e., locked plates or anatomically contoured plates) and fixation options that are biomechanically stable but potentially anatomically impeding (i.e., posterior antiglide plating).

Malalignment in plate osteosynthesis

The aim for this review is to present general considerations in relation to malalignment after osteosynthesis with plate fixation and its consequences after fractures in adults in each of the following anatomical locations: humerus, forearm, femur, tibia. Recommendations for accepted malalignment in humerus diaphyseal fracture is varus <20 degrees, valgus <15 degrees, sagittal deformity <5 degrees and rotation <30 degrees. Recommendations when treating fractures of the forearm is anatomical reduction. Varus of ulna leads to loss of pronation. Valgus of ulna leads to loss of both pronation and supination. Recommendations for acceptable malalignment in femoral fractures is rotational deformity <15 degrees, increasing varus deformity in intertrochanteric fractures increases load on implant. Cortical-step-sign, profile of lesser trochanter, evaluation of ipsilateral neck anteversion are intraoperative methods to avoid rotational malalignment. Recommendations for accepted malalignment in the tibia is shortening <10mm, varus/valgus <5 degrees, sagittal deformity <10 degrees. Fixation of fibula leads to less rotational and valgus malalignment, but not enough to affect union rate of tibia, complications rate or functional score at 12 months. To avoid malalignment in plating, pre-contoured anatomical plates are available from most manufactures. Being aware that most such plates fit a 50-percentile Caucasian population is important in pre-surgical planning. Evaluation of the contralateral bone and the characteristics of the plate may help in planning additional bending of pre-shaped plates and bending tools should always be available when applying a plate, even a so-called anatomical one.

Conservative Treatment Versus Repair Deltoid in SER Type IV Equivalent Ankle Fracture

Category: Trauma Introduction/Purpose: There remains a controversy to repair deltoid ligament in SER type IV equivalence of acute ankle fracture. Some surgeons prefer conservative treatment with casting while others prefer to repair deltoid ligament after distal fibular fixation. However, there is a little evidence to report comparative outcomes between the two methods. There remains a controversy to repair deltoid ligament in SER type IV equivalence of acute ankle fracture. Some surgeons prefer conservative treatment with casting while others prefer to repair deltoid ligament after distal fibular fixation. However, there is a little evidence to report comparative outcomes between the two methods. The purpose of this study was to report clinical and functional outcomes including complications between the two methods. Methods: A prospective, randomized collected data of 41 consecutive patients who were diagnosed with SER type IV equivalence acute ankle fracture and underwent either conservative treatment (20 patients) or deltoid repair (21 patients) between 2015 and 2017. A minimum follow up to be included in the study was 6 months (mean, 13.2 months; range, 6 to 30 months). The primary outcome was visual analogue scale (VAS), Short Form-36 (SF-36); physical and mental component scores, and FAAM; ADL and Sport. Pre- and post-operative SF-36, FAAM, and pain (Visual Analog Scale) were obtained and compared between the two groups using independent t-test. The secondary outcomes were time to return to activity of daily living, sports, work, and complications. Results: There were 41 patients (30 male and 11 female) with mean age of 29.7 years (range, 18-70 years) and mean BMI of 26.7 kg/m2 (range, 18.3-33.6 kg/m2). Both methods demonstrated significant improvement of post-operative functional outcomes (FAAM, SF-36, and VAS (p &lt; 0.05 all)) compared to pre-operative period; however, there was no significant different between the two groups. Functional outcomes between casting and deltoid repair groups were time to return to activity of daily living (10.4 vs 11.7 weeks), works (12.1 vs 12.9 weeks), sport (25.9 vs 23.7 weeks), weight bearing medial clear space (2.9 vs 3.9 mm), and complications included medial side ankle pain (57 vs 15%) and painful scar (0 vs 15%) for cast and deltoid repair respectively. Conclusion: Both casting and deltoid repair were demonstrated significant improvement in terms of functional outcomes as measured with the FAAM, SF-36, and VAS in patients with SER IV equivalent ankle fracture. Although there was no significant difference of functional outcome in short term of follow-up, deltoid repair group was better in term of medial side ankle pain and lesser medial clear space widening.

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p = .432). No significant difference was found in the complication rate (p = .914) or the reoperation rate (p = .291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.

Management of open Fractures of both Bones of Leg Treated by Internal Fixation of Fibula and External Fixation of Tibia

Management of open Fractures of both Bones of Leg Treated by Internal Fixation of Fibula and External Fixation of Tibia

Distal Tibia Delayed Union with Fibular Shortening Causing Syndesmotic Instability and Anterolateral Impingement

ABSTRACT Debate continues in the current orthopedic literature regarding advantages of performing concurrent fibular stabilization in combined distal tibial and fibular fractures. In this case report, we present the correction of tibial malalignment, fibular fixation, and syndesmotic restoration in a 21-year-old male after a high-energy injury where he sustained a fracture of the tibia and fibula at the same level that was initially managed with tibial nailing alone. After initially having delayed union, valgus malalignment and resultant syndesmotic pain and instability following the index surgery, he underwent revision surgery resulting in favorable recovery with cessation of his pain and correction of his malalignment. How to cite this article: Cantrell AJ, Wilson JA, Haleem A, et al. Distal Tibia Delayed Union with Fibular Shortening Causing Syndesmotic Instability and Anterolateral Impingement. J Orth Joint Surg 2019;1(1):31–34.

Distal tibia metaphyseal fractures: Which is better, intra-medullary nailing or minimally invasive plate osteosynthesis?

IntroductionTibia fractures are the most common long bone fractures encountered by the orthopedic surgeons and distal tibia fractures have the second highest incidence of all tibia fractures after the middle third of tibia the distal tibial fractures are unique and are considered as most challenging fractures to treat due to its proximity to the ankle joint and its superficial nature. The objective of this study is to compare two osteosynthesis systems developed for surgical treatment of distal tibia fractures: the intramedullary nailing and the MIPPO technique. MethodsThe study was conducted between Jan 2011 to Dec 2012. 63 patients with extra-articular distal tibia fracture treated with intramedullary nailing and MIPPO technique were reviewed retrospectively and clinical outcome was evaluated according to American Orthopaedic Foot and Ankle Score. Results31 patients were treated with intramedullary nail & 32 with MIPPO technique. Fibular fixation was done in cases where fibular fracture was at or below the level of tibial fractures. We found no difference in terms of time for fracture union, mal-union, non-union, duration of surgery and amount of blood loss. But there was significant difference in terms of infection and duration of hospital stay. Also weight bearing was possible much earlier in intramedullary group as compared to the MIPPO group. ConclusionThus we conclude that intramedullary nailing is better choice of implant in patients with extra- articular distal tibia fractures & helps in early weight bearing and ambulation of patient with fewer complications.

When is indicated fibular fixation in extra-articular fractures of the distal tibia?

Background and aim of the work: There is no consensus about indications for fibular osteosynthesis in extra-articular fractures of the distal tibia (DTF). This study analyses patients affected by DTF associated to fibular fracture and has the aim to define whether the level of fibular fracture has an influence on bone healing and consequently when its fixation is indicated. Methods: Eighty-seven patients were operated from January 2005 to December 2016. Inclusion criteria were: the presence of skeletal maturity, the absence of physical limitations before trauma and a type 43-A AO closed fracture. Clinical outcomes were evaluated using Olerud–Molander Ankle Score (OMAS) and the Disability Rating Index (DRI). Malrotation was also assessed as well as incidence of nonunion and malalignment through x-rays. Results: No differences in clinical scores were reported at follow-up between patients in which fibular fixation was performed (Group 1) in comparison with those in which this procedure was not executed (Group 2). Nonunions were registered in 8 cases: four in Group 1 and four in Group 2. A statistically significant difference in incidence of external malrotation and valgus malalignment between the groups was documented, with a higher risk in patients of the second group. Conclusions: The level of fibular fracture is important to determine when the fixation of this bone is indicated. In supra-syndesmotic fractures osteosynthesis leads to a higher incidence of nonunions. Fibular osteosynthesis could prevent malrotation and malalignment and is advisable in distal metaphyseal fracture of this bone (trans- or infrasyndesmotic lesion) with syndesmotic injury. (www.actabiomedica.it)

Intramedullary fibular fixation is a versatile tool in the operative management of fractures of the distal tibia and fibula

Category: Ankle, Trauma Introduction/Purpose: Intramedullary fixation of the fibula has been proposed as a minimally invasive alternative to traditional plate fixation in fractures of around the ankle. Previous studies have demonstrated a low complication rate, particularly when both distal locking and trans-syndesmotic screws are used. More recently, they have been used to act as a lateral buttress to prevent valgus malunion in fractures of the distal tibia and fibula. After four years of using fibular intramedullary devices in our unit we set out to audit our practice. Methods: We retrospectively searched our electronic operation database for operations in which fibular nails were used, from their first use in our unit in 2012 through to the end of 2016. Electronic operative and clinic notes were reviewed. We gathered basic demographic information and classified fractures according to the AO/OTA system, and studied pre- and post-operative radiographs for evidence of malunion. Results: Eighteen cases were identified. Median age at surgery was 66 (Range 23 to 83 years). Seven patients smoked, one was diabetic. Fibular nails were used in six in AO type 44 and twelve in AO type 42 and 43 fractures. Five were open. Fibular nails were used alongside tibial IM nails, tibial bridging plates, percutaneous tibial fixation and a tibial circular frame and were chosen because of concerns about poor soft tissues or wounds over the lateral side. Twelve cases had syndesmotic fixation. Median follow-up was five months (range 0-48 months). One nail was removed to compress a tibial fracture. All fractures united with no progressive malunion. One prominent distal locking screw was removed and one superficial wound infection required oral antibiotics. Conclusion: We have expanded the use of this device beyond the technique originally described. It’s use has been demonstrated across a range of fractures about the distal tibia and fibula in a variety of different operations with excellent results. Minimally invasive fibular nailing is particularly useful in patients with poor soft tissues or where there is high risk of post-operative infection.