SLR - February 2023 - Aneta Sokolowska, DPM
Title: Retrospective Analysis of Locked Versus Non-locked Plating of Distal Fibula FracturesReference: Sop A, Kali M, Spindel JF, Brown SM, Samanta D. Retrospective analysis of locked versus non-locked plating of distal fibula fractures. Injury. 2022 Dec 14:S0020-1383(22)00882-8. doi: 10.1016/j.injury.2022.11.049. Epub ahead of print. PMID: 36539311.
Level of Evidence: Retrospective Cohort Study, Level of Evidence III
Reviewed By: Aneta Sokolowska, DPM
Residency Program: Hoboken University Medical Center, Hoboken, NJ
Podiatric Relevance:
Ankle fractures are one of the most common types of fractures in adults with isolated lateral malleolus fracture being the most common kind. Many of the unstable fracture patterns require surgical treatment aiming to reduce the risk of post traumatic arthritis. Despite significant cost difference and no evidence of superiority in the existing literature when comparing traditional compression plating and locked plating for fixation of distal fibula, the use of the latter has significantly increased. The goal of this study was to compare the rates of reoperation due to implant failure or due to secondary infection when using locking and non-locking distal fibula plates.
Methods:
This retrospective study was performed at a level one trauma center over a ten-year period. Inclusion criteria involved age 18 or older, ORIF of unstable fibula fracture with locking or non-locking plates, and minimum three months of follow-up. Patient charts were reviewed by orthopedic trauma surgeons to identify whether patients were treated with a 1/3 tubular non-locking or pre-contoured locked plate and to establish the cause of reoperation. Means and standard deviations were conducted for continuous variables, whereas frequencies and proportions were reported for categorical variables. Continuous variables were compared using independent t-tests or Mann-Whitney U, and categorical variables were compared using chi-square or Fisher’s Exact test.
Results:
Out of 442 patients, 203 were identified in the non-locked 1/3 tubular plate group and 239 in the pre-contoured locked plate group. A total of 38 patients (8.6%) underwent hardware removal with a higher proportion of patients in the non-locked 1/3 tubular plate; yet, the use of syndesmotic screw was significantly higher in this group as well. Statistically significant differences in reoperation were found due to symptomatic implant in the non-locked 1/3 tubular plating group (78.3% vs. 46.7) and infection-related in the locked plate group (53.3% vs. 8.7%). Of patients who had device removal for symptomatic implant in the compression plating cohort, 13 (72.2%) had lateral positioning and 5 (27.8%) had posterior positioning whereas there was no statistical difference in plate positioning in the locked cohort. Of all medical comorbidities identified, only diabetes was associated with a higher rate of infection-related reoperations (83.3% vs. 15.6%).
Conclusions:
Overall, both traditional compression and locked plating techniques demonstrated low reoperation rates. Compression plating with 1/3 tubular plates placed laterally more often resulted in reoperation due to symptomatic implant but had fewer rates of infection as compared to locking plates. Therefore, authors concluded that placing traditional compression plates posteriorly may decrease the risks of symptomatic implant and infection, while keeping the costs of surgery significantly lower. Due to infection risks, it may be prudent to use 1/3 tubular non-locked plating in patients with increased risk factors such as smokers, diabetics and patient’s with PVD. How unstable ankle fracture is addressed depends greatly on the treating physician preferences; however, we must consider several other aspects including patient’s co-morbidities, cost of hardware, possibility of reoperation, and fracture type. We certainly should consider using traditional 1/3 tubular plates while choosing appropriate hardware.