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Surgical Pearls

Key Insights On Retrograde Intramedullary Fixation Of Distal Fibular Fractures

As foot and ankle surgeons, our main goals for operative treatment of ankle fractures include minimizing complications, anatomic alignment and reducing deformities. Treating unstable distal fibular fractures through a minimally invasive technique while still maintaining rigid and biomechanically functional fixation has always been a priority for surgeons. However, the minimally invasive approach has been limited in its challenge to the traditional open reduction internal fixation (ORIF) techniques with screw and plate constructs.

Minimal incision nailing techniques have once again become attractive to surgeons due to numerous studies indicating concern with complication and healing rates of screw and plate constructs.1 While multiple companies have created various forms of screw and plate constructs over the years ranging from one-third tubular plates to the newest anatomic locking plates, fixation of the lateral malleolus has changed little since the 1960s.

Many physicians argue that the fundamental screw and plate construct remains the gold standard, but recent studies have indicated concern with this procedure as researchers have noted complication rates of 30 percent.1 Screw and plate approaches can lead to postoperative complications such as wound dehiscence or infection (26 percent), painful hardware (50 percent) and mechanical failure (14 percent).2-4 Furthermore, these complication rates are even higher in the elderly population as well as patients with uncontrolled diabetes or neuropathy.5-6 This high incidence of complications is believed to be due to factors such as the size of the incision, the quality of bone stock or severe comminution of fractures, and the management of a patient’s comorbidities.

In a retrospective review, Miller and colleagues assessed 478 ankle fractures over a seven-year time period and found increased rates of wound complications in patients with a history of diabetes, peripheral neuropathy, and open fractures.7 Patients who also took wound-compromising medications (e.g. steroids) and were non-adherent with postoperative care had an increased incidence of wound complications.
Studies indicating concern with complications and healing rates of screw and plate constructs have prompted surgeons to return to procedures using minimal incision nailing techniques. The most prevalent method of this type of fixation is closed reduction with intramedullary interlocking nailing.

The advantages of retrograde intramedullary fixation are:

a) decreased lateral plate prominence;
b) reducing insult to the soft tissue envelope including a minimal incision and less disruption of adjacent neurovascular structures;
c) reducing irritation to peroneal tendons; and
d) stability in the setting of osteoporotic bone or severe comminution.

The case against the use of retrograde intramedullary fixation lies in potential disadvantages such as:

a) suboptimal alignment or rotational malalignment;
b) a technically demanding surgery; or
c) opting not to place locking screws, which reportedly increases the incidence of failure and fracture instability.8

What The Research Reveals About Retrograde Intramedullary Fixation

Many surgeons have utilized intramedullary fixation in a variety of clinical scenarios, an example being the Rush nails that were popular in the mid-1990s. Surgeons first used these nails in the elderly but the nails lacked reliable fixation.9 Further advancement in the technology has led to a wider array of nails available today with improvement in fixation quality.10-12 A review of the recent research shows promising results.
Smith and colleagues evaluated the biomechanical advantage of 20 cadaveric limbs in supination-external rotation (SER 4) type fractures using retrograde intramedullary fixation in comparison with a classic screw and plate construct.13 While retrograde intramedullary fixation never failed in that study, the associated lateral ankle ligaments ruptured in all limbs that had this fixation. In comparison, all 10 screw and plate constructs failures were due to hardware. The authors concluded that the fibular nail was significantly superior to the screw and plate construct.

White and coworkers published a prospective randomized control trial that compared retrograde intramedullary fixation with ORIF of ankle fractures in 100 elderly patients (>65 years).14 At one year, the authors found a significantly higher rate of infection in the ORIF group and no significant difference in mean functional scores. Furthermore, they found while the initial implant cost was higher for retrograde intramedullary fixation, the overall treatment cost was less than traditional ORIF when considering the financial impact of surgical complications.

In a level 2 prospective randomized controlled trial, Asloum and colleagues compared retrograde intramedullary fixation to traditional open reduction and internal fixation of non-comminuted fibular fractures without syndesmotic injury.15 The study found no significant difference in the rate of union between the two types of fixation. There were significantly fewer complications (7 percent versus 56 percent) and better functional scores with retrograde intramedullary fixation than with plate fixation.

Jain and coworkers performed a systematic review of 17 studies including 1,008 patients with distal fibular fractures who had subsequent retrograde intramedullary fixation.16 The authors found a mean union rate of 98.5 percent with a functional outcome as being good or excellent in up to 91.3 percent of patients. The mean complication rate across studies was 10.3 percent, which includes removal of hardware, fibular shortening and metal work failure. Also, the authors found no convincing evidence that retrograde intramedullary fixation was superior to standard techniques in terms of clinical and functional outcomes.

In Conclusion

Researchers have shown ORIF with screw and plate fixation of lateral malleolar fractures is an effective procedure over time, but the procedure also has higher complication rates in comparison to retrograde intramedullary fixation in multiple studies. The literature also suggests that retrograde intramedullary fixation is superior in biomechanical stability in comparison to the standard technique but shows no difference between the two approaches in clinical or functional outcomes.

Furthermore, there is no significant difference in the rate of union between the two types of fixation in numerous case reports and clinical studies extolling the reduced wound complications associated with nailing techniques. Lastly, the initial cost of retrograde intramedullary fixation is more expensive but may be a better long-term financial option in patients who are at high risk of experiencing complications.

As we conclude our discussion, it is important to understand the data is very limited with direct comparison of these two procedures. Further unbiased research is needed to truly appreciate a significant advantage to the use of retrograde intramedullary fixation versus traditional open reduction and internal fixation.

Dr. Potter is a first-year resident at Mercy Hospital in Chicago.

Dr. Martini is a second-year resident at Mercy Hospital in Chicago.

Dr. Hook is affiliated with Midland Orthopedics in Chicago.


  1. Lamontagne J, Blachut PA, Broekhuyse HM, O’Brien PJ, Meek RN. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002;16(7):498-502.
  2. Hoiness P, Engebretsen L, Stromsoe K. The influence of perioperative soft tissue complications on clinical outcomes in surgically treated ankle fractures. Foot Ankle Int. 2001; 22(8):642-648.
  3. McKenna PB, O’Shea K, Burke T. Less is more: lag screw fixation of lateral malleolar fractures. Int Orthop. 2007; 31(4):497-502.
  4. Beauchamp CG, Clay NR, Thexton PW. Displaced ankle fractures in patients over 50 years of age. J Bone Joint Surg. 1983;65(3):329-332.
  5. Anderson SA, Li X, Franklin P, Wixted JJ. Ankle fractures in the elderly: initial and longterm outcomes. Foot Ankle Int. 2008; 29(12):1184-1188.
  6. Wukich DK, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int. 2011; 32(2):120-130.
  7. Miller AG, Margules A, Raikin SM. Risk factors for wound complications after ankle fracture surgery. J Bone Joint Surg Am. 2012;94(22):2047-52
  8. Bulger KE, Watson CD, Hardie A, et al. The treatment of unstable ankle using Acumed fibular nail. J Bone Joint Surg Br. 2012; 94(8):1107-1112.
  9. Pritchett JW. Rush rods vs plate osteosynthesis for unstable ankle fractures in the elderly. Orthop Rev. 1993;22(6):691-696.
  10. McLennan JG, Ungersma JA. A new approach to the treatment of ankle fractures. The Inyo nail. Clinical Orthop Relat Res. 1986;213:125-136
  11. Rajeev A, Senevirathna S, Radha S, Kashayap NS. Functional outcomes after fibular locking nail for fragility fractures of the ankle. J Foot Ankle Surg. 2011;50(5):547-550.
  12. Burgler KE, Watson CD, Hardie AR, et al. The treatment of unstable fractures of ankle using the Acumed fibular nail: development of a technique. J Bone Joint Surg Br. 2012; 94(8):1107–12.
  13. Smith G, Mackenzie SP, Wallace RJ, Carter T, White TO. Biomechanical comparison of intramedullary fibular nail versus plate and screw fixation. Am Ortho Foot Ankle Soc. 2017;38(12):1394-1399.
  14. White TO, Bugler KE, Appleton P, et al. A prospective randomized controlled trial of the fibular nail versus standard open reduction and internal fixation of ankle fractures in elderly patients. Bone Joint Journal. 2016;98-B(9):1248-52.
  15. Asloum Y, Bedin B, Roger T, Charissoux JL, Arnaud JP, Mabit C. Internal fixation of the fibula in ankle fractures. A prospective randomized and comparative study: plating versus nailing. Orthop Traumatol Surg Res. 2014;100(4 Suppl):S255-9.
  16. Jain S, Haughton BA, Brew C. Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes. J Orthopaed Traumatol. 2014 ;15(4):245-254.
Surgical Pearls
By Ben Potter, DPM, Curt Martini, DPM, and Jonathan Hook, MHA, DPM
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