What are the indications and approaches for surgery on the distal fibula?

Surgical Indications and Approaches for Distal Fibula Fractures

Surgical fixation is recommended for distal fibula fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement to optimize functional outcomes and prevent long-term complications. 1

Indications for Surgery

The decision to pursue surgical intervention for distal fibula fractures should be based on the following criteria:

Radiographic Parameters

• Postreduction radial shortening >3 mm
• Dorsal tilt >10°
• Intra-articular displacement or step-off
• Unstable fracture patterns that cannot maintain adequate reduction with conservative management

Clinical Factors

• Ankle instability
• Displaced fractures that compromise ankle joint congruity
• Symptomatic avulsion fractures (os subfibulare) causing chronic pain 2
• Fractures with associated ligamentous injuries

Surgical Approaches

1. Open Reduction and Internal Fixation (ORIF)

• Traditional gold standard for unstable distal fibular fractures
• Provides direct visualization of the fracture site
• Allows anatomic reduction and stable fixation
• Typically uses plate and screw constructs

2. Minimally Invasive Techniques

These approaches have gained popularity due to reduced wound complications:

a) Minimally Invasive Plate Osteosynthesis (MIPO)

• Uses smaller incisions with subcutaneous tunneling
• Preserves periosteal blood supply
• Reported complication rate of 14.8% 3
• Good functional outcomes with mean AOFAS scores of 88.4 ± 3.40 3

b) Intramedullary (IM) Nailing

• Particularly beneficial for elderly patients with compromised soft tissues 4
• Requires smaller incisions
• Provides stable fixation with load-sharing properties
• Union rates of 98-100% 5
• Good to excellent functional outcomes in up to 92% of patients 5
• Complication rate approximately 10.3% 5

c) Intramedullary Screw Fixation

• Minimally invasive option for simple fracture patterns
• Reported complication rate of 13.7% 3
• Good functional outcomes in appropriately selected patients

Surgical Considerations

Timing of Surgery

• Early surgery (within 24-48 hours) is recommended when possible to facilitate anatomic reduction
• Delay may be necessary if significant soft tissue swelling is present

Implant Selection

• Autogenous vein should be used when possible for bypasses to below-knee structures 1
• For standard ORIF, anatomic plates designed specifically for the distal fibula provide optimal fixation
• For minimally invasive approaches, specialized IM nails or screws designed for the fibula should be used

Special Populations

Elderly Patients

• Traditionally treated non-operatively, but there has been a shift toward operative management
• Minimally invasive techniques like IM nailing show particular promise in this population 4
• Surgical treatment may help reduce mortality compared to non-operative management in the elderly

Postoperative Management

• Regular clinical and radiographic follow-up is essential
• Radiographic assessment at 12 months post-surgery is recommended
• Physical therapy to maintain joint range of motion and maximize strength and endurance

Potential Complications

• Wound complications (more common with ORIF than minimally invasive techniques)
• Implant-related issues requiring hardware removal
• Fibular shortening
• Hardware failure
• Malunion or nonunion (though rare, with union rates >98% for most techniques)

Clinical Pearls

• Consider minimally invasive techniques in patients with compromised soft tissues or multiple comorbidities
• Anatomic reduction is critical for restoring ankle joint congruity and preventing post-traumatic arthritis
• Address concomitant ligamentous injuries when present to optimize functional outcomes
• In patients with combined ankle instability and symptomatic os subfibulare, both issues should be addressed surgically for optimal outcomes 2