555712
research-article2014
FAIXXX10.1177/1071100714555712Foot & Ankle InternationalMitchell et al
Topical Review
Fixation of Distal Fibula Fractures:
An Update
Justin J. Mitchell, MD1, LCDR James R. Bailey, MD, MC, USN3,
Anthony E. Bozzio, MD1, Ryan R. Fader, MD1,
and Cyril Mauffrey MD, FACS, FRCS1,2
Level of Evidence: Level V, expert opinion.
Keywords: trauma, outcome studies, biomechanics, tendon disorders, statistical analysis
Introduction
Fractures of the fibula are common injuries treated by
orthopaedic surgeons and often require surgical stabiliza-
tion. Nevertheless, controversy remains with regard to the
optimal method of fixation. Studies have demonstrated that
anatomic reduction and fixation of the distal fibula improves
outcomes in patients with an unstable ankle mortise.12,25
Traditionally, fixation involved the use of a lateral one-third
tubular plate with bicortical screws proximal to the fracture
site and either unicortical or bicortical screws for distal
fragment fixation 2,4,12,19 However, some have cited poten-
tial disadvantages of this lateral fixation, including the pos-
sibility of intra-articular screw placement, painful hardware,
inferior biomechanical strength, inadequate distal fixation,
loss of fixation, and wound problems.4,5,12,15,20,21,37
In recent years, alternative methods of fixation have been
proposed including posterolateral plate fixation, locking plate
constructs, and the use of intramedullary devices. Since the
advent of these alternative techniques, there has been contin-
ued discussion and research regarding the use of these fixation
methods. As this is a potential area for continued and future
research and interest, we present a review of available litera-
ture to provide an update on current fixation techniques as well
as the challenges, benefits, and drawbacks of each.
Surgical Anatomy and Approaches
The distal fibula may be approached using either a direct
lateral or posterolateral approach. The direct lateral
approach is the most commonly utilized when performing
either lateral or posterior fixation. However, choice of
approach is influenced by surgeon preference, fracture type
and configuration, associated injuries, and status of the
skin.
With the direct lateral approach, exposure is relatively
straightforward. Nevertheless, care must be taken to protect
both the sural nerve posteriorly and the superficial peroneal
nerve anteriorly. The latter usually exits the crural fascia
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2014, Vol. 35(12) 1367­–1375
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DOI: 10.1177/1071100714555712
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approximately 12 to 14 cm above the ankle before dividing
in to the intermediate and medial dorsal cutaneous nerves.3
This anatomy is particularly relevant in fractures at or above
the level of the syndesmosis, where the superficial peroneal
nerve crosses directly in the field of dissection, placing it at
risk for transection or irritation.
The posterolateral approach to the distal fibula exploits
the interval between the peroneal tendons and the flexor hal-
lucis longus. With the patient in a lateral decubitus or prone
position, the incision is typically placed halfway between
the posterior border of the distal fibula and the lateral border
of the Achilles tendon. Following skin incision, the sural
nerve can be encountered and must be protected and gently
retracted. The peroneal tendon sheath is incised in line with
the incision. The peroneal tendons are retracted anteriorly to
expose the fibula and the flexor hallucis longus muscle
medially. Elevating the lateral fibers of the flexor hallucis
longus provides further exposure of the fibula and the poste-
rior tibia. Distal fibula fractures (and when necessary, a dis-
tal tibia fracture) can be debrided, reduced, and stabilized
through this approach. This incision; however, is often made
slightly posterior if the goal is posterior plating.
Surgical Fixation Techniques
Lateral Plating
A nonlocking plate has traditionally been used for direct lat-
eral fixation of the distal fibula (Figure 1). Proponents of
1
University of Colorado Hospital, Department of Orthopaedic Surgery,
Aurora, CO, USA
2
Denver Health Medical Center, Department of Orthopaedic Surgery,
Denver, CO, USA
3
Naval Hospital–Bremerton, Department of Orthopaedic Surgery,
Bremerton, WA, USA
Corresponding Author:
Cyril Mauffrey, MD, FACS, FRCS, Denver Health Medical Centre, 777
Bannock Street, Denver, CO 80204, USA.
Email: Cyril.mauffrey@dhha.org
1368 Foot & Ankle International 35(12)
Figure 1.  Preoperative (A) anterior/posterior and (B) lateral
radiographs of a displaced fibula fracture. Postoperative (C)
anterior/posterior and (D) lateral views of a direct lateral plate
on the fibula with the use of an interfragmentary compression
screw.
direct lateral plating maintain that this construct is simple,
provides sufficient biomechanical stability, and will not
lead to peroneal tendon pain or irritation. Techniques have
evolved over time (including the use of locked plating con-
structs as discussed in the following), but fixation using this
plate typically calls for at least 2 bicortical screws proximal
to the fracture site and 2 unicortical cancellous screws dis-
tally. There has been debate regarding the distal fixation and
the use of bicortical versus unicortical screws.20,29
Proponents of the use of bicortical screws argue that this
provides superior fixation to unicortical fixation with can-
cellous screws.15,18 Conversely, those in favor of unicortical
screw placement point to the possibility of intra-articular
screw placement with the use of bicortical screws.38,40
The use of an interfragmentary lag screw (Figure 1) has
been employed for increased compression and stability in
oblique fibular fractures.19,20 Lag screw only fixation of the
long oblique fracture of the lateral malleolus has also been
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used and has demonstrated equivalency to plate fixation in
young patients with good bone stock. This technique is safe
and effective, with limited dissection and less prominent
hardware.17,34 However, it is reserved for use in long oblique
fractures and is not a viable option for individuals with
comminuted fractures, osteoporosis, limited compliance
with weightbearing, or irreducible syndesmotic injury.34
Various authors have reported unsatisfactory fixation
and decreased fixation strength with unicortical cancellous
fixation, especially in osteoporotic or comminuted bone.14,16
This can lead to loss of fixation as well as delayed or non-
union.2,4,6 While locking and posterior plating may obviate
these risks, authors have attempted to provide means by
which standard nonlocking constructs with adjunct fixation
could be used, including the use of carefully placed bicorti-
cal screws in the distal fragment or tetracortical fixation
using tibia-pro-fibula (syndesmotic) screws14,20,24 (Figure 3).
Panchbhavi et al24 investigated this strategy and found that
when compared with the same construct without additional
screws, tetracortical fixation demonstrated a 9% increase in
torque to failure, 24% increase ability to withstand external
rotation, and a 34% increase in energy before failure of the
construct. This fixation technique adds little operative time,
is inexpensive, and is a technically straightforward method
to increase the stability of the construct.24
Posterior Plating
In 1982 Brunner and Weber proposed the use of a posterior
antiglide plate as a new method of fibular fixation. They
concluded that posterior plating was advantageous as it was
biomechanically superior and avoided the soft tissue com-
plications associated with subcutaneous plate placement.6
The use of posterior plating in lieu of lateral fixation remains
controversial. Advocates of posterior plate application
argue that the concern for intra-articular screw penetration
is voided with posterior to anterior screw placement. Other
potential benefits include less dissection and operative time,
minimum bending of the plate, and the fact that distal screw
fixation may be unnecessary.30,35,37,39,40 Nevertheless, this
technique entails dissection of the peroneals and potential
irritation by the plate.
Similar to lateral plating, a one-third tubular plate is typi-
cally used. At least 2 bicortical nonlocking screws are
placed through the most proximal portion of the plate
(Figure 2). The posterior plate and the typical orientation of
the fracture line (apex postero-superior) create an axilla.
The plate configuration thereby forms an antiglide con-
struct, and although used by some surgeons, distal fragment
fixation is not required.15,21,30,39,40 In fact, some authors
advocate not filling the distal hole with a screw as they
believe that screw head is what causes peroneal irritation
with this construct.37 An interfragmentary compression
screw may also be placed through the plate perpendicular to
Mitchell et al 1369

Figure 2.  (A) Anterior/posterior and (B) lateral radiographs of a displaced fibula fracture with posterior malleolar and syndesmotic
injury. (C) Demonstrates posterior plating construct for a distal fibula fracture in conjunction with posterior plate fixation of the
posterior malleolar fragment and TightRope (Arthrex, Napes, FL) fixation of the syndesmosis.

the fracture in a traditional lag fashion. This requires plan-
ning when placing the plate such that an accessible screw
hole is appropriately oriented.
Wissing et al40 reported on the potential advantages of
posterior antiglide plating in a retrospective review of their
cases’ arguing that in cases of severe soft tissue injury, a lat-
eral plate caused more skin irritation. In addition, the shape
and bony structure of distal fibula is not uniform, and a lateral
plate must be contoured in order to sit directly against the
bone, which may result in a biomechanically disadvantaged
construct. Finally, the thin lateral cortex gives rise to
decreased purchase with distal laterally based screws that can
penetrate the distal tibiofibular and fibulotalar joints.
Distal Fibular Locked Plating
Short, oblique fractures of the distal fibula are typically
amenable to fixation using the techniques described previ-
ously. However, in patients with diminished bone stock or
severely comminuted fractures, obtaining adequate fixation
can be challenging. Locking plates have been reported as an
alternative form of fixation in these cases.13,16,21,24 Locked
plating is well described and relies on the interaction
between plate and screw to create a fixed angle device. The
periarticular nature of the distal fibula makes distal bicorti-
cal fixation difficult. The biomechanical advantages of a
fixed angle device, however, allows for the use of unicorti-
cal screws as it obviates the need for both bicortical fixation
and compression between the plate and bone to stabilize the
fracture.11,38,41 The locking mechanism prevents screw
toggle and back out, which may be exacerbated with the use
of conventional plates in patients with deficient bone
stock.41
Recently, there has been increased interest in the use of
distal fibular locking plates in comminuted or osteoporotic
fractures.9,11,16,28 Locking plates exist in one-third tubular
form or in anatomically contoured options. These plates are
typically larger and stronger with a flare at the distal aspect
of the fibular metaphysis to provide multiple options for
locking unicortical distal fixation. Smaller (eg, 2.7 mm)
screws may be incorporated into the plate design. In addition
to options for increased distal fixation, minimally invasive
plate osteosynthesis with locked plating has also been used
in those patients with increased risk for wound complica-
tions, infection, and high rates of complications such as the
elderly and in those with diabetes or neuropathy.11,13,16,21
Intramedullary Fibular Nail
Locking plates have shown promise in treating comminuted
or osteoporotic fractures of the distal fibula, but potential
drawbacks exist. Plate fixation may not be possible in frac-
tures with associated soft tissue compromise or in elderly
patients with fragile skin.6,10,15 There has therefore been
renewed interest in the use of a retrograde screw or fibular
nail for such patients (Figure 4).7,27,28,32
Retrograde nail fixation is typically performed through a
small transverse incision at the distal aspect of the fibula. A
guidewire is inserted in the center of the distal fibula and a
reamer is used to breach the distal cortex. Closed reduction

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1370 Foot & Ankle International 35(12)

Figure 3.  (A) Photograph of an open ankle fracture dislocation after a ground level fall in a 76-year-old female with osteoporosis and
diabetes mellitus type II. (B) Anterior/posterior and (C) lateral radiographs of her immediate reduction are shown, along with (D, E)
postoperatiave radiographs demonstrating tetracortical fixation in the setting of a displaced fracture of the lateral malleolus.

is used to hold the fracture in alignment, although mini-
mally invasive reduction and adjunctive Kirschner wire
fixation can also be used. Insertion of the nail follows in a
retrograde fashion. Proximal and distal locking holes are
available to set rotation and alignment, although this is not
always performed. Proponents of this fixation cite several
advantages including limited exposure, indirect closed
reduction, lack of lateral plate prominence, and decreased
risk of peroneal tendon irritation.7,27
There are, however, potential disadvantages associ-
ated with this strategy including the potential for subop-
timal reduction or rotational malalignment. The technique
can also be technically demanding with regard to the
placement of percutaneous locking screws, and surgeons
that have chosen to forgo this step of the procedure have
noted an increased incidence of failure and fracture
instability.7
Outcomes/Literature Review
Few studies have directly compared various distal fibular
fixation techniques. Nevertheless, several recent investiga-
tions have examined clinical outcomes, complications, and
biomechanical profiles individually.

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Mitchell et al 1371
Figure 4.  (A) Photograph of a right ankle in a 76-year-old female who fractured her distal fibula after stepping off of a curb. Anterior/
posterior radiograph of the injury is shown in (B), and anterior/posterior radiograph of fixation with a fibular nail is shown in (C).
(Image courtesy of Acumed, LLC, Hillsboro, OR, Mason Miller, Representative).
Clinical Outcomes
Clinical outcomes following fixation of distal fibula frac-
tures focus on fracture union, wound healing, pain relief,
restoration of motion, and ankle stability. Several studies
have recently reviewed the outcomes for operatively treated
ankle fractures.
The efficacy of fibular fixation with a lateral plate has
been well studied as it relates to union, function, and activ-
ity.4,5,10,12,18-20,24,25 Available studies that focus primarily on
fixation with one-third tubular plates report that the most
important prognostic factors following operative treatment
include anatomic reconstruction of the articular surfaces and
restoration of fibular length and alignment.2,4,6,12,19,25 Other
than malreduction, negative prognostic factors include a
delay in fixation greater than 4 weeks post injury, injury to
ligamentous structures around the ankle, associated tarsal/
metatarsal fractures, and neuropathy or vasculopathy.5,12,14
Still and Atwood33 recently retrospectively reviewed 41 oper-
atively treated ankle fractures using several operative tech-
niques. Using a modification of the American College of
Foot and Ankle Scoring Scale (ACFAS),8 male gender was
the only independent variable that statistically increased the
likelihood of a satisfactory subjective result. Obesity, smok-
ing, sustaining a high fibular fracture, or undergoing syndes-
motic repair decreased the likelihood of a satisfactory result.
There have been several studies examining clinical out-
comes following posterior plating. In a prospective evalua-
tion of 32 Weber B fractures treated with posterior plating,
Ostrum23 reported that 100% of fractures healed unevent-
fully. There were no nonunions, malunions, wound compli-
cations, loss of fixation, or intra-articular screw penetration.
Four patients had transient peroneal tendon pain, and 2
patients had later plate removal for symptomatic interfrag-
mentary screw. Twenty of 21 patients who returned a ques-
tionnaire were satisfied with their results.
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In a review of 93 patients treated with posterior plating,
Winkler et al39 reported 67% excellent, 28% good, and 5%
poor results at 1-year follow-up. The results were better in
young male patients. In another series, Treadwell and
Fallat35 reported on 71 Weber B fractures in 70 patients.
They reported only 1 case of premature loosening of fixa-
tion prior to fracture union and 2 cases of peroneal tendini-
tis related to the distal positioning of the plate. The
symptoms of the latter patients resolved with plate removal.
Lamontagne et al15 retrospectively reviewed the out-
comes of a lateral plate construct compared to antiglide
plating in 193 patients with isolated displaced lateral fibula
fractures. There was 1 case of lost fixation in a noncompli-
ant patient in the antiglide group. Otherwise, there were no
nonunions or malunions reported and the authors found no
statistical significance in terms of operative time, tourni-
quet time, duration of hospital stay, wound healing compli-
cations, or hardware removal rates. They concluded that
despite some biomechanical evidence suggesting superior-
ity of antiglide fixation, no statistical difference was seen in
clinical outcomes.22
There are few clinical outcome studies specifically eval-
uating locked plating for distal fibula fractures. Tsukada et
al36 performed a randomized controlled trial of 57 patients
randomized to either locking plate fixation or nonlocking
fixation. No statistically significant difference was observed
in the radiographic rate of bone union, SF-36 score, or time
to resolution of tenderness at the fracture site.36
Studies regarding outcomes following the use of fibular
nails are limited. Appleton et al1 reviewed 37 patients who
underwent fixation of unstable ankle fractures with lateral
talar shift using a fibular nail. All patients were over the
age of 60 years with poor bone quality and/or had signifi-
cant medical comorbidity or soft tissue trauma that was not
amenable to standard fixation. Average follow-up was 58
weeks, and the average Olerud and Molander Score (OMS)
1372 Foot & Ankle International 35(12)
at final follow-up was 87 out of 100. Average ankle dorsi-
flexion at final follow-up was within 4 degrees of the unin-
jured ankle and plantar flexion was within 3 degrees. More
than 85% of patients regained ankle motion to within 90%
of the uninjured side. Radiographically, all but 1 patient
had normal medial clear space and talocrural angle mea-
surements. Another retrospective review of 24 patients
with displaced fragility fractures of the distal fibula treated
with fibular nail yielded good function and patient satisfac-
tion at 1 year.27 All patients had initial displacement of the
fracture with loss of the lateral buttress and went on to frac-
ture union at an average of 8.7 weeks with no wound com-
plications, deep infection, or deep venous thrombosis.
Additionally, in their study of 11 patients treated with fib-
ula nailing in elderly osteoporotic patients, Ramasamy and
Sherry28 reported excellent results and no wound compli-
cations in 88% of cases.
In the largest series to date, Bugler et al7 examined the
results for 105 patients treated with fibular nail for unstable
ankle fractures. Anatomical reduction was achieved in 96%
of patients, while 46% had a good outcome, 40% had a fair
outcome, and 14% had a poor outcome using OMS. Of
note, however, reliability of these results may not be ade-
quate as various configurations of locking screws were used
throughout the study process. The initial constructs con-
sisted of distal locking screws with a proximal blocking
screw to prevent proximal migration, distal locking screws
alone, a syndesmotic screw alone, or no fixation. In this first
subset of patients, nail fixation without locking screws
achieved rotational and longitudinal stability in only 66%
of cases, while those with locking screws demonstrated
greater than 90% stability. These results led to a change in
technique, which included syndesmotic fixation in addition
to a distal locking screw. The current recommended tech-
nique calls for antero-posterior distal locking screw to sta-
bilize the distal fragment and allow for rotation and
anatomic reduction prior to the insertion of a transverse
syndesmotic screw above the fracture, which locks the nail
in place.
Soft Tissue Complications
Soft tissue complications and painful hardware are cited as
the main indications for hardware removal in the postopera-
tive period.5,15,25,31,33,36,37,39 Brown et al5 examined the
incidence of soft tissue complications in patients who
underwent open reduction and internal fixation of a short
oblique fibula fracture with a lateral plate. The authors uti-
lized the Short Form-36 (SF-36) Survey and the Short
Musculoskeletal Functional Assessment (SMFA) to obtain
patient information and to compare results. Thirty-one
percent of patients reported pain overlying their lateral
hardware. In general, the SF-36 and SMFA scores at final
follow-up were significantly lower for patients who had
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pain overlying their lateral hardware than for those who had
no pain. Twenty-three percent either had their hardware
removed or desired to have it removed. However, only 50%
of those who underwent hardware removal had improve-
ment in their lateral ankle pain. To this end, no significant
difference was noted in SMFA or SF-36 scores between
patients who had their lateral hardware removed and those
who had not. These results suggest that the lateral implant
may play less of a role in the sensation of pain than other
authors have suggested and could be related to cutaneous
neuralgia from the incision, concomitant soft tissue injury,
or loss of motion related to tibiotalar joint stiffness.
With regard to posterior antiglide plating, Winkler et al39
reported that 42 of 93 plates (45%) were removed by 1 year
following surgery. The authors did not expand as to why the
plates were removed. In that retrospective series reported
by Lamontagne et al15 comparing lateral and posterior anti-
glide fixation of the distal fibula. The authors found a trend
toward increased incidence of hardware removal (17% vs
13%), discomfort (12% vs 7%), and wound dehiscence or
infection (4% vs 1%) for lateral plate fixation when com-
pared to a posterior antiglide plate, although these differ-
ences were not statistically significant. Moreover, they
found no statistically significant difference in operative
time, tourniquet time, or length of hospital stay.
Weber and Krause37 performed a retrospective review of
70 patients treated with posterior antiglide plating in an
attempt to identify the location of peroneal tendon lesions
as they relate to plate position and how this relates to the
need for later hardware removal. In addition to this, they
performed dissection of the retromalleolar space in 10
cadavers to study the anatomic variability of the peroneal
groove. The plate was removed in 30 patients (43%) because
of discomfort and/or physical exam findings suggestive of
peroneal irritation. They noted that peroneal tendon lesions
were identified in only 9 of the 30 patients (30%) at the time
of hardware removal. Two of these 9 patients had peroneal
symptoms preoperatively, while the remaining patients had
their plates removed at the physician’s suggestion based on
physical exam. The authors found that plate position did not
correlate with peroneal tendon lesions but rather that place-
ment of a prominent or oblique screw in the most distal hole
of the plate did. In cadaveric dissection, the shape of the
peroneal groove was uniform and did not contribute to
peroneal lesions or irritation. Based on these findings, they
recommended not filling the most distal hole of the plate.
With regard to locked plating, Schepers et al31 conducted
a retrospective clinical study of 205 patients evaluating the
complication rates in fixation of the distal fibula using a
locking plate compared with those procedures using the
nonlocking plate. Of the 40 patients who underwent fixa-
tion with locked plating, 7 had wound complications; and of
the 165 patients treated with the nonlocking plate, 9 had
wound complications. The rate of wound complications
Mitchell et al 1373
observed with the use of the locking plate was significantly
higher than that with the nonlocking plate. Meanwhile,
Tsukada et al36 did not find any differences in wound com-
plications when comparing locking and nonlocking plates
and further did not report any instances of plate removal at
1-year follow-up. These studies differed in that Tsukada’s
group used anatomically precontoured locking plates while
Schepers et al did not.
The data on complications associated with fibular nail
fixation are limited. In the previously referenced series by
Bulger et al,7 a small subset of all patients (5%) underwent
revision surgery for failure of fixation. However, as previ-
ously noted, surgical technique changed over time, and
early fixation modalities were without locking screws. In
this initial subset, 78% of patients experienced no compli-
cation. However, 5 patients developed a postoperative
infection, and 7 patients failed by loss of fixation. Five of
these required revision surgery. With the advent of the new
fixation method that included the use of a syndesmotic
screw, there was only 1 failure of fixation, and this occurred
in a patient that was noncompliant with postoperative
weightbearing precautions. Five (5%) patients had postop-
erative wound infection and 16 patients (15%) underwent
hardware removal.
Biomechanics
In an attempt to answer the question of biomechanical supe-
riority, Shaffer and Manoli30 performed a cadaveric study
comparing the strength of traditional lateral plating with
posterior antiglide plating of the distal fibula. Short oblique
fractures were created in 24 fresh-frozen cadaveric lower
extremities. The extremities were then statically and axially
loaded using a biaxial electrohydraulic testing system fol-
lowing reduction and fixation with either a lateral or poste-
rior antiglide plate. Ten fibulae were fixed with a contoured
one-third tubular plate without lag screw fixation. Fourteen
fibulae were fixed with posterior one-third tubular antiglide
plate. Two bicortical 3.5 mm screws were used in the proxi-
mal fragment without distal fixation. All specimens were
loaded to failure using a supination external rotation force.
The last 10 consecutive specimens in the antiglide plate
group were retested after being replated with new screw
holes and a supplemental lag screw placed through the
plate. Fibulae fixed with antiglide plates had a significantly
higher failure torque when compared to those fixed with
lateral plates. Antiglide plates also demonstrated signifi-
cantly higher stiffness and energy absorbed before failure
(364 Newton meter degrees vs 290 Newton meter degrees).
The authors were unable to demonstrate a significant differ-
ence between the antiglide plate group and the antiglide
plate plus lag screw group.
Minihane et al21 subsequently performed a biomechani-
cal comparison between posterior antiglide and lateral
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locking plate fixation for displaced short oblique fractures
of fibula in osteoporotic bones. Fixation of 18 fresh frozen
ankles paired by bone mineral density (BMD) following
DEXA scan was performed. Simulated SER IV fractures
were created. Nine fractures were stabilized with a lateral
one-third tubular locking plate with an independent lag
screw while 9 were stabilized with a nonlocking posterolat-
eral antiglide plate augmented with a lag screw through the
plate. Significantly higher (P = .01) torque to failure and
significantly higher (P = .005) construct stiffness was iden-
tified in bones fixed with posterior plates. No differences in
angular rotation at failure were identified.
Other authors have reviewed biomechanical differences
of fibulae fixed with locked plating compared to those
fixed with one-third tubular plates.11,13,38,41 Zahn et al41 per-
formed a biomechanical study of 10 cadaveric specimens
that underwent open reduction, internal fixation (ORIF)
following simulated rotational fibula fractures at the level
of the syndesmosis. Five underwent contoured traditional
nonlocking fixation while 5 others were stabilized with
contoured lateral locking plates. The specimens were then
torsionally loaded to failure. Specimens fixed with con-
toured locking plate demonstrated a higher torque to fail-
ure, angle to failure, and higher maximal torque when
compared to specimens stabilized with conventional plates.
Additionally, torque to failure in the locking group was
independent of BMD, while those in the nonlocking group
failed earlier with decreasing BMD.
Similar studies by Kim et al13 and White et al38 failed to
demonstrate a significant difference in torque to failure,
rotation to failure, or energy to failure, between distal fibu-
lar locking plates, or nonlocking one-third tubular plates.
Kim et al13 demonstrated that 2 fewer unicortical locking
screws are needed to achieve the same biomechanical sta-
bility found with 3 traditional unicortical nonlocking screws
and reinforced that distal fibular locked plating was inde-
pendent of BMD, while nonlocking one-third tubular plat-
ing had improved performance with increasing BMD.
Eckel et al9 recently performed a comparison of 4 differ-
ent lateral plate constructs. The comparison included 2 sep-
arate locking plates from different manufacturers with
adjunctive lag screw fixation and 2 nonlocking plates from
different manufacturers. The authors found a positive cor-
relation between increasing BMD and improved bending
stiffness for all plate types. However, they found no other
significant differences in plate performance with regard to
torsional stiffness or fracture site rotation.
Conclusion
While the focus of this article addresses surgical strategies
to improve fixation of distal fibular fractures, it is important
to remember that the quality of reduction remains the most
critical step in treating an ankle fracture operatively. Well
1374 Foot & Ankle International 35(12)
fixed yet poorly reduced fractures are associated with poor
outcomes. Nevertheless, surgeons must be familiar with
available fixation options as well as the potential advan-
tages and disadvantages of each technique.
Biomechanically, antiglide plating appears superior to
lateral plating and locking constructs. Although locking
plates may provide some mechanical advantage, they have
not been shown to be clinically superior to traditional plat-
ing systems. Robust data to support the use of fibular nails
are lacking, but these implants do appear to provide reliable
stability with newer techniques and may prove useful in
elderly patients with comminuted osteoporotic fractures or
patients with substantial soft-tissue compromise.
Questions remain regarding the optimal fixation of the
distal fibula, especially in the setting of osteoporotic or
comminuted fractures. Currently, the choice of fixation
should be based on clinical judgment, patient factors, and
surgeon comfort. Prospective randomized studies further
comparing various forms of fixation are necessary.
Authors’ Note
The opinions or assertions contained herein are the private views
of the authors and are not to be construed as official or as reflect-
ing the views of the Department of the Navy or the Department of
Defense.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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