SLR - October 2023 - Heidtmann
Title: Evidence-Based Orthopaedics In Adults Aged 65 Years with Unstable Ankle Fractures: Fibular Nailing Did Not Differ from Open Reduction and Internal Fixation for Functional Outcome at 1 YearReference: White TO, Bugler KE, Olsen L, Lundholm LH, Holck K, Madsen BL, Duckworth AD. A Prospective, Randomized, Controlled, Two-Center, International Trial Comparing the Fibular Nail With Open Reduction and Internal Fixation for Unstable Ankle Fractures in Younger Patients. J Orthop Trauma. 2022 Jan 1;36(1):36-42. doi: 10.1097/BOT.0000000000002140. PMID: 33878069.
Level of Evidence: I, prospective randomized controlled trial
Scientific Literature Review
Reviewed by: Alexandra Heidtmann
Residency Program: Highlands- Presbyterian/ St. Luke’s
Podiatric Relevance: Among recent technical advances, intramedullary fixation for unstable ankle fractures has been shown to restore ankle stability while providing reduced rates of wound dehiscence and infection, when compared to plate fixation. While this device has an obvious advantage for elderly patients, its application on younger patients is still in question. The study compares fibular nailing and open reduction and internal fixation (ORIF), to determine their impact on functional outcomes, in patients under the age of 65 years.
Methods: 125 patients with unstable ankle fractures, aged 18 to 64 years, underwent either fibular nail fixation (n=63) or ORIF (n=62). Exclusion criteria included patients unable to give informed consent/ cognitive impairment, bilateral injuries or ipsilateral injuries to the lower limb, pilon fractures, and patients unable to comply with follow-up. The primary outcome measure was patient-reported function using the Olerud and Molander Score (OMS) at 1 year, with secondary outcomes measured at different time points up to 2 years. The study was randomized and unblinded.
Results: The average follow-up was 24 months. The study found that fibular nailing and ORIF did not result in significant differences in functional outcomes at 1 year or any other assessment up to 2 years (OMS 78.4 in the nail group vs. 80.2 in the plate group). There were 2 patients who suffered wound infection in the nail group, and 9 patients in the plate group, but this did not reach statistical significance. Additionally, there were no significant differences between the two groups in terms of return to the operating room, final anatomic reduction rates, overall complications, or individual complications such as hardware removal, infection, nerve injury, reduction loss, or pulmonary embolism.
Conclusion: In adults aged 65 years and younger with unstable ankle fractures, fibular nailing did not show a significant difference in functional outcomes compared to ORIF at the 1-year follow-up. Even though the benefit of reduced wound complications is not as apparent in younger patients compared to the elderly, fibular nail is an effective and safe option for the stabilization of ankle fractures in younger patients.