Surgical vs non-surgical management of Weber B fractures: A systematic review

No difference in early outcomes comparing intramedullary versus extramedullary fibular fixation in operative ankle fractures

INTRODUCTION

The purpose of this study was to compare postoperative complications and outcomes of minimally invasive intramedullary fixation (IMF) versus plate fixation (PF) in the treatment of distal fibular fractures.

MATERIALS AND METHODS

A retrospective review was performed from identifying all consecutive ankle fracture patients aged ≥18-years-old surgically managed between August 2017 to September 2022 at a tertiary care center with minimum 6 months clinical follow-up. Patients were grouped into those receiving intramedullary versus extramedullary fibular fixation. The primary outcomes were relevant demographic factors (diabetes, osteoporosis, charlson comorbidity index [CCI]), surgical time, complication rates, reoperation rates. Secondary outcomes included time to definitive fracture fixation, fracture characteristics (AO/OTA and Lauge-Hansen classification), syndesmotic instability requiring fixation and discharge disposition.

RESULTS

Forty-one IMF patients (average age 55.3 ± 18.1yrs) and 162 PF patients (47.7 ± 17.4yrs) were identified and included in this study. Within the IMF group, 25 patients received IM nailing and 16 patients received percutaneous screw fixation. A greater proportion of IMF patients had diabetes (39 % vs 22 %, p < 0.001), osteoporosis (22 % vs 3 %, p < 0.001), and moderate or severe CCI (41 % vs 23 %, p = 0.017). Surgical time was significantly reduced when using IMF technique (80.4 ± 43.1 min vs 99.1 ± 43.1 min, p = 0.012). Overall complication rates or time to complication did not differ significantly between groups (p = 0.578 and p = 0.082, respectively); however, when sub-stratified, IMF patients trended towards experiencing fewer wound related complications versus PF patients (5 % vs 9 %, p = 0.291). No IMF patients experienced deep or superficial infections and only 2 (5 %) patients experienced wound dehiscence. Reoperation rates(15 % vs 10 %, p = 0.267) and time to fracture union (2.7 ± 2.2 mos vs 3.1 ± 2.0 mos, p = 0.301) did not differ significantly. At final follow-up (IMF: 15.0 ± 12.2 mos vs PF: 28.5 ± 19.5 mos), Olerud and Molander ankle score was significantly higher in IMF compared to PF (87.1 ± 14.2 vs 76.2 ± 22.6, p = 0.002).

CONCLUSION

Patients in the IMF group at baseline had several comorbid medical conditions that put them at high risk for wound related complications, however, postoperatively they demonstrated higher functional scores and similar complication rates compared to the PF group. It is important to note, however, while we expected a higher rate of wound issues with the PF group, there were no significant differences in infection rates. Either IMF and PF is reliable for fixation and outcomes, and thus with proper soft tissue, biologically friendly technique, either IMF or PF is a reliable choice in the fixation of fibula fractures.

LEVEL OF EVIDENCE

III, retrospective cohort comparison study.

Syndesmotic fixation in Weber B ankle fractures: A systematic review

Weber Type B fractures often arise from external rotation with the foot supinated or pronated. Altered tibiofibular joint kinematics in Weber B fractures are responsible for syndesmotic damage seen in Weber B fractures. Weber B fractures are managed using open reduction and internal fixation if displaced. The syndesmosis is injured in up to 40% of cases resulting in an unstable injury with a syndesmotic diastasis. This systematic review aimed to evaluate the current literature on syndesmotic fixation in Weber B fractures, assess the outcomes and complications of syndesmotic fixation and assess the necessity of syndesmotic fixation in Weber B fractures. A search was carried out on the EMBASE, PubMed and CINAHL databases and eight studies assessing the outcomes of syndesmotic fixations versus no syndesmotic fixation with 292 Weber B ankle fractures were included in this systematic review. Results showed significant heterogeneity so a narrative review was conducted. Results of these studies showed that functional, radiological, and quality-of-life outcomes and incidences of post-traumatic osteoarthritis in patients with syndesmotic screws were similar to those of patients not managed with syndesmotic screws. Only one favoured syndesmotic fixation in all cases of diastasis. As such, syndesmotic fixation with screws may not be necessary in the management of Weber B fractures. Screws are also associated with breakage, loosening, local irritation and infections. Suture button devices and antiglide fixation techniques appear to be valid alternatives to syndesmotic screws. It was found that there was no need for routine hardware removal unless the hardware was causing significant side effects for the patient.

Cast versus removable orthosis for the management of stable type B ankle fractures: a systematic review and meta-analysis

PURPOSE

There is currently no consensus on nonoperative management in adult patients after a stable type B ankle fracture. The aim of this review is to compare a removable orthosis versus a cast regarding safety and functional outcome in the NOM of stable type B ankle fractures.

METHODS

A systematic review and meta-analysis were performed using randomized clinical trials and observational studies. The methodological quality of the included studies was assessed with the methodological index for non-randomized studies instrument. Nonoperative management was compared using the number of complications and functional outcome measured using the Olerud and Molander Score (OMAS) or the American Academy of Orthopaedic Surgeons Ankle Score.

RESULTS

Five studies were included. Two were randomized clinical trials, and three were observational studies, including a total of 516 patients. A meta-analysis showed statistically significant higher odds of developing complications in the cast group [odds ratio (OR), 4.67 (95% confidence interval (CI) 1.52-14.35)]. Functional outcome in OMAS did not vary significantly at 6 weeks, mean difference (MD) - 6.64 (95% CI - 13.72 to + 0.45), and at 12 weeks, MD - 6.91 (95% CI - 18.73 to + 4.91). The mean difference of functional outcome in OMAS at 26 weeks or longer was significantly better in the removable orthosis group; MD - 2.63 (95% CI - 5.01 to - 0.25).

CONCLUSION

Results of this systematic review and meta-analysis show that a removable orthosis is a safe alternative type of NOM, as complication numbers are significantly lower in the orthosis group. In addition, no statistically significant differences were found in terms of functional outcome between a removable orthosis and a cast at 6 and 12 weeks. The 6-week and the 26-week OMAS results show that in patients with stable type B ankle fractures, a removable orthosis is non-inferior to a cast in terms of functional outcome.

Intramedullary Screw Fixation Versus Traditional Plating for Distal Fibula Fractures

The traditional method of treating fibular fractures in unstable ankle injuries involves open reduction and internal fixation with a plate and screw construct. Less invasive percutaneous fixation techniques with intramedullary fibular screws have been utilized for many years to reduce wound and implant complications while maintaining a stable ankle mortise. However, there have been no direct case-control studies comparing percutaneous intramedullary fibular screw fixation to the traditional open reduction and internal fixation with plates and screws. In our study, we compared radiographic and clinical outcomes for unstable ankle fractures in which the fibula fracture was treated with either a percutaneous intramedullary screw or by open reduction and internal fixation with a plate and screw construct. We retrospectively reviewed 69 consecutive patients from 2011 to 2019 with unstable ankle fractures treated with intramedullary fibular screws and compared them to 216 case-control patients treated with traditional plate and screw construct over the same time period. The average follow-up for the intramedullary screw group was 11.5 months and 15.2 months for the plate and screw group. We collected general demographic data, measured intraoperative and final follow-up talocrural angles, Kellgren-Lawrence osteoarthritis grade, union rates, implant removal rates, infection rates, and American Orthopedic Foot and Ankle Society ankle-hindfoot scores. The intramedullary screw group had a statistically significant lower rate of delayed implant removal (8.7% vs 23.6%) and there was no detectable difference in other measures.

Surgical treatment of displaced isolated lateral malleolar fractures: incidence of adverse events requiring revision: a retrospective cohort study

BACKGROUND

Recent systematic reviews support that non-operative management should be the standard treatment for all stable isolated lateral malleolar fractures (ILMFs), regardless of fibular fracture displacement. Surgical fixation of ILMFs carries a risk of adverse events (AEs), and many patients will later require implant removal. We wanted to estimate the incidence of AEs requiring revision after surgical fixation of "potentially stable" displaced ILMFs before non-operative treatment became standard care in our department.

MATERIALS AND METHODS

To identify patients with "potentially stable" ILMFs who had been treated surgically in a historical cohort, we retrospectively applied the stability-based classification system, introduced by Michelson et al., to a cohort of 1006 patients with ankle fractures treated surgically from 2011 to 2016. The primary outcome of this retrospective cohort study was the incidence of AEs that had functionally significant adverse effects on outcome and required revision in the first 12 months after surgery. AEs were graded and categorized using the Orthopedic Surgical Adverse Events Severity (OrthoSAVES) System.

RESULTS

The study population comprised 108 patients with "potentially stable" displaced ILMFs; 4 patients (3.7% [95% CI (0.1-7.3%]) experienced AEs requiring revision in the first twelve months after surgery. There were 5 additional patients (4.6%) with functionally significant AEs where revision surgery was not indicated within the first twelve months after surgical fixation. A further 5 patients (4.6%) had AEs managed in the outpatient clinic (grade II); 36 patients (33.3%) required secondary implant removal due to implant-related discomfort.

CONCLUSIONS

Surgical fixation of ILMFs carries a risk of severe AEs, and many patients will subsequently need implant-removal procedures. Further prospective studies are required to ascertain whether non-operative treatment can lower the risk of AEs and the need for additional surgical procedures.