Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review

Abstract

Introduction: The purpose of this systematic review and meta-analysis was to provide an update of the recent literature comparing clinical outcomes of surgically treated fibular fractures using intramedullary nailing (IMN) with open reduction and internal plate fixation (ORIF).

Methods: A literature search reporting clinical outcomes after IMN or ORIF of the distal fibula was conducted on PubMed. Inclusion criteria consisted of original studies; studies focusing on clinical outcomes after IMN or IMN and ORIF published before May 11, 2022; studies with at least 5 patients; and studies reporting union rates, complication rates, and patient-reported outcomes such as American Orthopaedic Foot and Ankle Society (AOFAS) and Olerud-Molander scores.

Results: Of 2,394 studies identified, a total of 29 studies (4 LOE-I, 2 LOE-II, 6 LOE-III, 17 LOE-IV) were included consisting of 1,850 IMN patients and 514 plate patients. The pooled mean age of IMN patients was 58 years (95% confidence interval [CI], 54 to 62, I2 = 42%) versus 57 years (95% CI, 53 to 62, I2 = 49%) in ORIF. Union rates for IMN patients revealed a 99% union rate (95% CI, 0.98 to 1.00, I2 = 20%) versus 97% union rate for ORIF patients (95% CI, 0.94 to 0.99, I2 = 0%). Studies that compared IMN with ORIF revealed no difference in union rates (risk ratio [RR] = 0.99, 95% CI, 0.96 to 1.02, I2 = 0%). IMN patients showed a 15% complication rate (95% CI, 0.09 to 0.23, I2 = 89%), whereas plate patients had a complication rate of 30% (95% CI, 0.18 to 0.46, I2 = 63%). When comparing studies with both treatments, IMN patients had a significantly lower risk of complications (RR = 0.49, 95% CI, 0.29 to 0.82, I2 = 50%). The IMN group trended toward a higher mean AOFAS and Olerud-Molander score than the plate group by 4.53 (95% CI, -14.58 to 23.65, I2 = 85%) and 3.54 (95% CI, -2.32 to 9.41, I2 = 76%) points, respectively.

Conclusion: Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation. While IMN patients had higher AOFAS and Olerud-Molander scores, these differences were not statistically significant. Notably, subgroup analyses indicated that rates of symptomatic implant and removal of implant were comparable between IMN and ORIF, which may indicate that wound-related complications were reduced in the minimally invasive IMN technique. While the high cost of IMN implants remains a barrier to their widespread adoption, the long-term benefits of reducing complications, specifically associated with wound complications in high-risk populations, may greatly improve quality of care for patients with distal fibula fractures. Additional research and cost-effectiveness analyses are warranted to fully assess the long-term benefits and economic feasibility of using IMN fixation for distal fibula fractures.

Level of evidence: Therapeutic Level IV.

Figure 1

PRISMA flow diagram of literature search results and screening. PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

Figure 2

Graph showing surgical time in studies reporting both (positive RR indicating higher surgical time in IMN than in plate fixation). CI = confidence interval, HK = Hartung-Knapp, RR = risk ratio, SE(TE) = standard error of the treatment effect, TE = treatment effect.

Figure 3

Graph showing time to surgery in studies reporting both (positive RR indicating higher time to surgery in IMN than in plate fixation). CI = confidence interval, HK = Hartung-Knapp, RR = risk ratio, SE(TE) = standard error of the treatment effect, TE = treatment effect.

Figure 4

Graph showing IMN-only union rate pooled analysis. CI = confidence interval.

Figure 5

Graph showing plate-only union rate pooled analysis. CI = confidence interval.

Figure 6

Graph showing union rates in studies reporting both (positive RR indicating higher rates in IMN than in plate fixation). CI = confidence interval, RR = risk ratio.

Figure 7

Graph showing IMN-only overall complication rate pooled analysis and subgrouped analysis for symptomatic implant/implant removal. CI = confidence interval.

Figure 8

Graph showing plate-only complication rate pooled analysis and subgroup analysis for symptomatic implant/implant removal. CI = confidence interval.

Figure 9

Graph showing complication rates in studies reporting both and subgrouped analysis for symptomatic implant/implant removal (positive RR indicating higher rates in IMN than in plate fixation). CI = confidence interval, RR = risk ratio.

Figure 10

Graph showing IMN versus plate: AOFAS score in studies reporting both (positive indicates higher score for IMN). AOFAS = American Orthopaedic Foot and Ankle Society, CI = confidence interval, HK = Hartung-Knapp, SE(TE) = standard error of the treatment effect, TE = treatment effect.

Figure 11

Graph showing IMN versus plate: Olerud-Molander scores in studies reporting both (positive indicates higher score for IMN). CI = confidence interval, RR = risk ratio, SE(TE) = standard error of the treatment effect, TE = treatment effect.