Fibular Intramedullary Nails: Indications, Trends, and Recent Results

Ankle fractures are among the most common presentations to the emergency department, accounting for approximately 9% of all fractures.¹ Mechanisms of injury range from a simple ground-level fall to a high-energy motor vehicle accident, posing a unique challenge to providers. The incidence of ankle fractures ranges from 140 to 187 per 100,000 people per year and is slated to increase, secondary to the growing geriatric population and increased participation in sporting activity.^2,3 Men are more likely to suffer an ankle fracture in their younger years, whereas women more often sustain these injuries after age 50.² Ankle fractures and their outcomes can be significantly influenced by several medical comorbidities, including obesity, smoking, diabetes, advanced age, and peripheral vascular disease.⁴

A multitude of complications comes with treating ankle fractures including, but not limited to, wound healing challenges, periprosthetic fractures, and morbidity due to non-weight-bearing status.⁵ These complications are especially present in the aforementioned comorbid patients. Additionally, reoperations for ankle fractures are common (11% Weber A, 37.8% Weber B, 51.2% Weber C),⁶ inducing an increased cost to the patient and health system, further anesthesia risk, and potentially more complications.^5,6

To potentially reduce risks, surgeons have turned to the use of intramedullary (IM) fixation. This surgical modality has gained popularity in recent years; however, it has been performed for decades with success.^7,8 Surgeons traditionally reserve IM fixation in the lower extremity for tibial and/or femoral fractures, hindfoot fusions, and revisional surgeries; however, its application in fibular fractures has garnered interest as of late.

Historically, open reduction and internal fixation (ORIF) has been the gold standard for surgically treating ankle fractures.⁹ ORIF offers advantages of achieving anatomic alignment and a stable, reliable framework for securing the fracture, utilizing the well-established AO techniques. Given the presence of comorbid conditions, some foot and ankle surgeons may lean towards a more conservative approach for minimally displaced or non-displaced ankle fractures.¹⁰

Is there a surgical approach that strikes a happy medium? In our experience, IM fixation for the fibula, while it may not follow the conventional AO techniques, is an appealing alternative to ORIF. Benefits include less anatomic dissection, less prominent hardware, and earlier time to weight-bearing versus the more traditional and historically implemented plate and screw construct.¹¹ IM nails offer relative stability as they do not compress across the fracture site, which deviates from the primary fixation offered by the more traditional ORIF. IM fixation has mostly been reserved for the elderly, patients with diabetes or PVD, or those with significant soft tissue compromise, with the attractive advantages for both the surgeon and the patient. New literature has shed light on the effectiveness and expansion of the utility of IM fixation for fibular fractures (Figure 1).

Anatomic and Biomechanical Considerations

A potential concern with IM fibular nail placement is the ability to properly reduce the fracture(s) and/or visualize vital surrounding structures, avoiding inadvertent injury. An anatomic study revealed the fibular IM nail is effective in reducing fibular fractures in terms of rotation, length, and syndesmotic diastasis, but did not completely reduce translation.¹² Some have found a minimally invasive approach to open reduction is sometimes necessary to adequately reduce fibular fractures, even with IM fibular rod placement.¹³ Another anatomic study, detailing the risk of injury to surrounding structures with IM nail placement into the fibula, found no significant injuries to the peroneal tendons or superficial peroneal nerve, which are the structures at highest risk of injury.¹⁴ This study also recommends a skin-only incision with blunt dissection down to bone (tip of the fibula) to avoid damage to these adjacent structures. The insertion point of the fibular nail is relatively safe anatomically and protects structures which may be at higher risk with traditional ORIF and its customary incisions.

The IM fibular nail allows for adaptability to place flexible or rigid trans-syndesmotic fixation through the nail itself. Of note, this feature was not present in first- and second-generation nails. As with traditional ORIF constructs, malreduction of the syndesmosis is also a concern with IM fibular nails.¹² How does the fibular nail stack up compared to more traditional fixation in this regard? There is a poorer prognosis for ankle fracture repair following malreduction of the syndesmosis,¹⁵ so this question is of utmost importance as fibular nail placement indications are changing to a younger population.

Though not directly compared to plate fixation, Bastias and colleagues set out to investigate anatomic restoration of the syndesmosis using an IM fibular nail.¹² They found this fixation method allows restoration of the anatomical parameters of the ankle in terms of fibular rotation, length, and syndesmotic diastasis. However, fibular translation had significant differences compared with the uninjured ankle based on bilateral computed tomography (CT) evaluation. In this study, it is worth mentioning rigid fixation was used through the fibular nail, which may have contributed to the syndesmotic malreduction. Flexible fixation, when compared to rigid trans-syndesmotic fixation, exhibits a lower syndesmotic malreduction rate.¹⁶ The ability to place flexible trans-syndesmotic fixation through the fibular nail may be advantageous. Additional head-to-head comparisons of syndesmotic reduction abilities of the nail and traditional plating/screws are still necessary. Based on the literature available,¹² postoperative CT scans are recommended for proper evaluation of the syndesmotic reduction, should there be a concern.    

Comparable biomechanical properties have been described between the fibular IM nail and the standard lateral plate fixation. Smith and colleagues compared ORIF to IM nail fixation and demonstrated the fibular nail had superior torque to failure and improved position maintenance versus traditional plating with a lag screw.¹⁷ This is advantageous, especially in a potentially nonadherent subset of patients who are feared to bear weight sooner than advised, or in patients who are unable to remain non-weight-bearing secondary to their age or comorbid conditions. It should be noted that in this study, the fibular nail group had trans-syndesmotic fixation placed where the plate group did not, potentially adding more inherent stability to this fixation construct. A similar study found the IM nail group had less external rotation stiffness in highly unstable ankle fractures.¹⁸ Syndesmotic diastasis was comparable between the fibular nail group and the plate group, both of which utilized a single trans-syndesmotic screw.¹⁹ Carter and colleagues demonstrated the load to failure was similar using a locking plate versus an intramedullary nail in unstable geriatric ankle fractures in a cadaveric biomechanical comparison.²⁰

If biomechanically equivalent or superior, one should consider IM fibular fixation for displaced or unstable ankle fractures, though more evidence would be beneficial.

Indications and Contraindications for Fibular IM Nails

With the emergence of newer literature and technology, there appears to be expanding indications and narrowing contraindications for the fibular IM nail. Classically, descriptions of fibular nail utilization were of patients with ankle fractures and significant comorbidities, such as tobacco use, type 2 diabetes, peripheral neuropathy, end-stage renal disease, alcoholism, and osteoporosis.^21-23 Additionally, those patients may be of advanced age, have skin compromise (i.e., fracture blisters, extreme swelling), or involve a general concern for nonadherence. ORIF has traditionally been reserved for younger, active patients, Weber C, pronation external rotation (PER) injuries, trimalleolar fractures, and comminuted fibular fractures.²⁴

Diabetes. Patients with diabetes are at increased risk for wound healing complications and loss of fracture fixation with standard ORIF.^25,26 When feasible, physicians may choose nonoperative management for this demographic, and subsequent delays in healing or further ankle deformity may occur.²⁷ As already discussed, less dissection of the soft tissue envelope and a small incision are benefits of the fibular nail. There is less periosteal stripping, which provides better local blood delivery to the fracture site itself.²⁸ Ashman and colleagues found low reoperation rates for wound healing issues, low complication rates, and favorable functional outcomes in patients with diabetes with unstable ankle fractures.²⁹ Studies theorize the utility of the fibular IM nail in patients with diabetes,^21,22,29 but these authors were unable to find any studies with a direct comparison of fibular IM nail to ORIF or nonoperative management. This warrants future comparative studies in this patient population.

High energy trauma. High-energy and/or unstable fractures have not typically been fixated with fibular IM nails; however, we find some recent literature supports this approach in those with the aforementioned comorbidities and risks.²² Overall maintenance of IM nail alignment has been of some concern; thus additional adjunctive fixation can be considered in those with syndesmotic injuries or unstable ankle fractures.²² Although there appear to be numerous indications for the fibular nail, there is no literature to date discussing its utility in comminuted distal fibular fractures. Rather, a spanning bridge plate is the historically accepted choice for these types of fractures.

Emerging literature is beginning to change the indications for the fibular IM rod for some providers, including in pilon and other unstable ankle fractures.^22,30 Faber and colleagues demonstrated comparable outcomes with the use of fibular IM nails in lieu of lateral plating for pilon fractures.³⁰ However, further studies are needed to establish a direct comparison between standard plating and the use of a fibular nail for pilon and other high-energy fracture patterns, as there is a paucity of literature. The potential advantages of the IM nail in high-energy traumas are worth discussing. With the inherent risk of skin compromise due to excessive swelling or open fractures, the IM nail may be a viable alternative for fibular fixation to help preserve the already compromised soft tissue envelope. Hopefully, future studies will explore using the fibular nail to treat unstable and high-energy ankle fractures as we continue to broaden the scope of use. Less is known in regard to IM fibular nail use in Weber C ankle fractures, as most of the available literature discusses Weber A and B fractures only. Further studies on using the fibular IM nail in Weber C fractures would also be valuable. 

Elderly patients. The geriatric population is one of the most classically described populations for use of the fibular IM nail. The nail offers less dissection through brittle skin and leaves a smaller wound to heal, less operating room time, and ultimately less anesthesia risk.³¹ Those of advanced age exhibit significantly higher rates of postop delirium, cognitive dysfunction, and increased morbidity and mortality.³² Secondly, the nail offers earlier ambulation, even potential immediate weight-bearing, which may decrease fall risk and skilled nursing requirements and provides a stable construct.³³ With this in mind, the fibular nail may decrease insufficiency fracture-related morbidity and mortality in this demographic.

The incidence of geriatric fractures increases with rising age.¹ There are relatively low surgical complication rates for fibular fractures, but there is substantially increased 1-year mortality in both nonoperative and operative groups after a fibular fracture.¹ Nonoperative management of geriatric fibular fractures had a 2-fold increase in mortality, with operative intervention having a protective effect compared to the conservative group.¹ However, providers may have reserved conservative management for frailer, more comorbid individuals with a higher baseline risk of morbidity and mortality.

Locking plates are typically utilized for osteopenic and osteoporotic bone, though this does require significantly more dissection and risks wound healing complications. One option to avoid significant dissection is minimally invasive plate osteosynthesis (MIPO), which has shown promising results in this population.³⁴ There is minimal literature showing direct comparisons between MIPO and IM nails, though current studies show that IM fibular nailing has significantly lower wound healing complications but may not reduce the fracture rotation completely.^35,36 Also, MIPO still requires adequate edema control preop, which may delay surgery and pose additional risk. Barlow and colleagues showed early weight-bearing had a significant effect on the patient’s ability to maintain independent living and likelihood to return home.³⁷ This would have a great impact on their overall physical and emotional well-being postop, ideally decreasing morbidity and mortality in the elderly population.

Pediatric patients. Of note, there is a paucity of literature to describe the use of IM nailing for pediatric fibular fractures. Odéhouri-Koudou and team showed satisfactory results of IM nailing in various locations, including the fibula, in children.³⁸ However, the sample size was small and there was no direct comparison between the nail and traditional plating. Further studies to evaluate the IM nail in pediatric ankle fractures requiring operation would be of future interest, though we understand the indications in this population are likely scarce.

Comparing Plates With IM Nails

The key question is then, how does the IM nail compare to a more traditional plate and screw construct for fibular fractures? Numerous studies compare the approaches, most of them very recent, as this technique has garnered popularity. Overall, the literature consistently shows lower complication rates with the fibular IM nail.^31,39-41 A 2022 level 1 study found sufficient quality of evidence in the current studies available to conclude that there is no clinical difference between the IM nail and ORIF 12 months postoperatively.⁴² With that being said, there were reduced complications with the IM nail as previously discussed, and no difference in union rates⁴² (Figure 2).

As previously discussed, multiple demographics may find benefit with the fibular IM nail, especially those at high risk.²² In contrast, a 2021 retrospective comparative study looked at patients between 18 and 50 years old with AO-OTA 44B or C fractures (Weber B and C included) who participated in sports or higher-level activities.⁴³ They found the IM nail group had poorer radiographic reduction on CT compared to ORIF, especially in Weber C, PER, trimalleolar, and comminuted fibula injuries. Although reduction was not as good with the fibular nail, there were significantly fewer complications and there were no differences in clinical outcomes between groups. While the IM nail may not always provide the same reduction as ORIF, the clinical outcomes differences are negligible indicating the IM nail is an adequate option compared to ORIF in young, active patients.⁴⁴ Of note, we suspect newer advances in fibular IM fixation will aid in correcting these downfalls and continue to provide adequate patient satisfaction, currently supported by recent literature.^20,45-50

At this time, plate fixation does appear to be superior for anatomic reduction as discussed,⁴¹ but further studies are required to assess for any significant long-term negative sequelae after IM fixation of the fibula. Overall, there is a lower risk of implant removal, lower complications, and earlier return to weight-bearing in the appropriate patient with IM fixation of distal fibular fractures.^49,51-53 Newer literature suggests the possibility of achieving sufficient syndesmotic stabilization through the utilization of IM fixation, thereby potentially broadening its already expanding range of indications.^12,54

Additionally, the IM nail has not been shown to have a higher learning curve compared to standard fixation,¹¹ making its ease of use an added benefit. Lastly, as discussed as a benefit within the geriatric population, early return to weight bearing gets our patients back on their feet.

In Conclusion

We believe IM nailing for stabilization of fibular fractures should be in the surgeon’s armamentarium for fixation options. The fibular nail offers less dissection, lower complication rates, earlier weight-bearing, and adequate reduction and stabilization of fibula fractures with good functional outcomes. Newer literature hints at our ability to push the boundaries for the use of these nails in high-energy and unstable ankle fractures and in patterns with syndesmotic instability. Multiple studies show similar, if not superior, overall results in a head-to-head comparison between the fibular nail and ORIF of fibular fractures. Further literature on pediatric patients, Weber C, PER, and comminuted fibular fractures are required to adequately analyze its utility in these populations as well as long-term follow-up results.

Our goal with this article is not to advocate for the use of fibular IM nails, as this will be at the surgeon’s discretion, but rather our intention is to highlight the current literature, recent trends, and outcomes with this fixation method.

Ian Barron, DPM, FACFAS, is a board certified foot and reconstructive rearfoot/ankle surgeon. He practices at Gentle Foot Care - A Division of Ohio Foot & Ankle Specialists.

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