1017373

research-article2021
FASXXX10.1177/19386400211017373Foot & Ankle SpecialistFoot & Ankle Specialist

vol. XX / no. X Foot & Ankle Specialist 1

〈 Clinical Research 〉
A Comparison of Fibula
Pro-Tibia Fixation Versus
Alistair Ian Eyre-Brook, BMed, MRCS ,
Joseph Ring, BSc, FRCS,
Carolyn Chadwick, MBChB,

Hindfoot Nailing for Unstable

FRCSEd (Tr&Orth),
Howard Davies, BSc (Hons),
FRCS (Tr&Orth) ,

Fractures of the Ankle in

Mark Davies, BM, FRCS (Tr&Orth),
and Chris Blundell, BMedSci (Hons),
FRCS (Tr&Orth)

Those Older Than 60 Years

Abstract: Background: Ankle and higher rates of delayed wound fractures in the elderly population have
fractures in the elderly are an healing (P = .03) and nonunion (P = been shown to be poor regardless of a
increasing problem, with poor .001). Multivariate analysis identified nonoperative or operative management
outcomes reported. Operative options fixation and age to affect revision method, with a randomized control trial
for patients with suspected osteoporosis rates. Conclusion: Outcomes were reporting an equivalent outcome with
and needing to bear weight to worse in the IMN group compared with close contact casting compared with
ambulate can include hindfoot FPT. We believe both techniques have operative fixation.4,5 Failure of operative
intramedullary nail (IMN) or fibula a role in the management of elderly fixation can lead to significant
pro-tibia fixation (FPT). FPT involves ankle fractures, but patient selection is complications such as loss of fracture

“
passing 2 or more screws through key. We suggest
a lateral fibula plate, crossing the that FPT should
fibular into the tibia, with 1 or more be the first- . . . the optimal treatment of unstable ankle
screws proximal to the incisura. We choice technique
compared the outcomes of these 2 when soft tissues fractures in the elderly remains unclear.”
techniques. Method: A retrospective permit.
review identified 68 patients aged over
Levels of
60 years with unstable ankle fractures, position, nonunion, malunion, soft tissue
Evidence: Level III
treated with IMN or FPT. Primary compromise, failure of metal work, and
outcome was surgical reoperation/ Keywords: ankle fracture; elderly; need for revision surgery. These risks are
revision rate, secondary outcomes osteoporosis, fracture fixation; high and figures of 48% and 73%,
included complications, length of postoperative complications respectively, for malunion and nonunion
stay, and functional status. Results: have been reported.5-7 As a result, the

A
There were no significant differences nkle fractures in the elderly are an
in demographics between IMN and increasing problem, particularly in
FPT. Revision rates were higher older female patient.1-3 Kannus
2
in IMN compared with FPT (P < et al demonstrated an age-adjusted
.0001). IMN patients postoperatively increase in fragility ankle fractures in
had longer hospital stays (P = .02), elderly women of 164% between 1970
longer follow-up times (P = .008), and 2000.2 Outcomes following ankle
optimal treatment of unstable ankle
fractures in the elderly remains unclear.8
There are a range of operative
techniques described for the operative
treatment of unstable ankle fractures,
which include open reduction and
internal fixation with nonlocking or

DOI: 10.1177/19386400211017373. From Northern General Hospital, Sheffield, UK. Address correspondence to: Alistair Ian Eyre-Brook, BMed MRCS, Northern General
https://doi.org/

Hospital, Herries road, Sheffield, S5 7AU, UK; e-mail: ally5012@gmail.com.

For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2021 The Author(s)
2 Foot & Ankle Specialist
locking plates, intramedullary devices of
both the fibula and/or tibia and fixation
methods, including trans-syndesmotic
fixation.9-11 In cases where there is
concern regarding the bone quality and
likely need to require a fixation that
allows weightbearing to ambulate,
techniques such as intramedullary
hindfoot nailing (IMN) and fibula
pro-tibia fixation (FPT) are considered in
our unit. FPT is the preferred fixation
option in these cases; however, if the soft
tissues are felt not to tolerate a direct
lateral fibula approach, then IMN
provides a minimally invasive option to
stabilize the ankle. Joints are not
prepared prior to IMN insertion to avoid
unnecessary disruption to the soft
tissues.
FPT fixation is a relatively new concept
that provides additional stability by using
the tibia as an internal strut; passing
locking screws proximal to the incisura
through the plate and fibula into the
tibia. This technique can allow patients
to ambulate early despite the concern of
poor-quality bone. Early ambulation is
particularly useful in patients with poor
mobility prior to their ankle fracture by
helping them keep their independence.
Although there are studies detailing the
use of both IMN and FPT, there have
been no studies comparing these
techniques. The aim of the present study
is to review our experience of the
operative treatment of unstable ankle
fractures in a population aged over 60
years using these 2 techniques.
Materials and Methods
A retrospective review was conducted
looking at operatively treated unstable
ankle fractures in patients over the age
of 60 years between January 2012 and
January 2018 performed at the Northern
General Hospital, Sheffield, UK. Using
the operating department management
system (ORMIS, Oracle), all ankle
fractures that had undergone operative
fixation in this time period were
identified. A subsequent notes review
was conducted to assess for patient age,
sex, comorbidities and details of soft
tissue condition. The ankle fracture
pattern was assessed using the digital
images on the picture archiving and
communication system (PACS), and
patients who had IMN or FPT were
identified.
All patients were given a Charlston
Comorbidity Score; a validated method
of predicting a patient’s 10-year
mortality using their age and
comorbidities, which includes
diabetes.12 In addition, we collected
data on operative time, length of
hospital stay, complications,
reoperations, outcomes, and dual-
energy X-ray absorptiometry (DEXA)
results performed within 6 months of
surgery. Fracture risk assessment tool
(FRAX) was used to calculate each
patient’s risk of future fracture. This
gives a score of 10-year osteoporotic
related fracture risk and classifies
patients into low, medium, or high risk
based on this score. The FRAX score
can be used in isolation or combined
with a bone density measurement
depending on the patient’s level of risk
and local treatment guidelines. With
regard to the DEXA scan it is the
T-score which is most useful when
screening patients for osteoporosis. This
is the bone density score compared
with a healthy 30-year-old. A T-score of
greater than −1.0 is normal, a score of
between −1.0 and −2.5 indicates
osteopenia and a score of −2.5 or lower
indicates osteoporosis. It has been
shown that when compared to patients
with a normal bone mineral density
osteopenia can result in a 1.8-fold
increase in fracture rate and
osteoporosis increases the risk 4-fold.13
We wanted to review ankle fracture
fixation techniques in patients with
suspected osteoporotic bone at time of
surgery. We chose to exclude patients
less than 60 years of age as we felt that
fixation techniques may be used for
reasons other than suspected
osteoporotic fracture. Additional
exclusion criteria included any patients
who underwent definitive treatment
using other techniques such as
manipulation under anesthesia, standard
plate fixation, fibula nails, or external
fixation. In addition, we excluded
Mon XXXX
Figure 1.
(a) Mortice radiograph of intramedullary
nail fixation. (b) Lateral radiograph of
intramedullary nail fixation.
patients who had fractures not involving
the malleoli (eg, extra-articular distal
tibial fractures). Open fractures, diabetic
and neuropathic patients were included.
These exclusion criteria identified 27
IMN and 41 PFT from an initial cohort of
1417 cases. Finally, we selected the
6-year time frame to include a minimum
of 12 months of follow-up on the 2
patient groups.
Similar to Al-Nammari et al patients
who were deemed too frail to manage
restricted weightbearing postoperatively
were considered for these 2 fixation
techniques. The decision to treat these
cases with either IMN or FPT was made
by the treating surgeon and on-call
consultant at the time of admission. The
decision was based on a combination
of factors: whether the distal lateral
malleolar fragment could be held with
plating; the quality of soft tissues; and
operating surgeon technique
preference.
Radiographs were reviewed by 3 of
the authors to assess fracture pattern
and fixation technique. IMN were all
performed using the T2 Ankle
Arthrodesis Nail (Stryker), inserted as
per the Stryker operative technique
(Figure 1). We emphasize that the
joints were not prepared to reduce soft
vol. XX / no. X
Figure 2.
(a) Mortice radiograph of fibula pro-
tibia fixation. (b) Lateral radiograph
of fibula pro-tibia fixation.
tissue insult and a long nail was used
where possible. The FPT was
performed in a supine position using a
lateral fibula approach. Following
fracture reduction, a Stryker Variax
Distal Lateral Fibular plate (Stryker) was
applied. A combination of locking
screws are then used with a minimum
of 2 screws applied through a lateral
fibula plate, crossing the fibula into the
tibia, with one or more of these placed
proximal to the incisura (Figure 2). The
number and configuration of fibula
pro-tibia screws depend on fracture
type and bone quality.
The primary outcome was surgical
reoperation/revision rate, to determine
the effectiveness of IMN and FPT for
ankle fractures in patients with suspected
osteoporotic bone. Secondary outcomes
were complications, length of hospital
stay, and functional status, to assess the
relative safety of each of these
treatments, the potential health care
impacts, and return to function in each
of the patient groups.
Statistical analysis was performed using
SPSS for Windows V25.0 (IBM Corp).
Chi-square tests were used for categorical
data, unpaired t tests for continuous
parametric data and Mann-Whitney for
nonparametric data. A binary regression
analysis was performed to rule out
confounders for our primary outcome;
reoperation rate. A P value of less than
.05 was considered significant.
Results
We identified 68 patients with
unstable ankle fractures; 27 were
treated with IMN and 41 with FPT. The
procedures were performed by 16
different surgeons; 8 of these were
consultants who either performed or
scrubbed supervising all cases. All 8
consultants performed both IMN and
FPT fixations. The patient demographics
of both groups are summarized in Table 1
and injury pattern in Table 2.
All patients in both cohorts had
medium or high FRAX scores
suggesting that they were at increased
risk for a hip of major osteoporotic
fracture compared with the normal
population. In those patients that
warranted DEXA scans, 19 FPT and 7
IMN, average DEXA T-scores were
−1.65 (range 2.4 to −2.7) in the FPT
group and −1.93 (range 1.5 to −3.8)
there was no statistically significant
difference between bone mineral
density between the groups (P = .47).
These results suggest that both groups
have an average T-score indicating
osteopenia.
Reoperation rate was significantly
lower in patients treated with FPT
compared with IMN (2 vs 12 Fisher’s
exact test, P < .0001). The 2 patients
requiring reoperation following FPT
fixation were both for prominent
syndesmosis screws at 5 months
post-FPT fixation. The revisions in the
IMN group were due to 5 metalwork
failures, 3 painful nonunion of medial
and lateral malleoli, 1 painful nonunion
of isolated medial malleolus, 1 painful
nonunion of fibula, 1 surgical placement
error, and 1 deep infection. In the case
of surgical placement error, the
calcaneal entry point was placed too
medially resulting in early cut out of the
medial cortex of the calcaneum on the
postoperative radiographs. In 10
patients the intramedullary nail was
removed, with 5 requiring further
treatment in a below knee cast for
between 7 and 26 weeks. Of these 5
Foot & Ankle Specialist 3
cases requiring casting, 4 went on to
unite; the nonunion was managed
long-term in an ankle foot orthosis as
they were unfit for any further surgery.
One case of those who had
intramedullary nail removal required an
Ilizarov frame for painful nonunion 5
months following initial fixation. At 3
months, the Ilizarov frame failed and
was subsequentially managed in a total
contact cast for a further 4 months, at
which time the fracture had united. In
the case of deep infection involving the
nail, the patient had their metalwork
removed 5 months after the index
surgery and the defect was filled with
pure calcium sulfate loaded with
vancomycin and gentamicin. Close
contact casting was then applied for 6
weeks followed by 6 weeks in a fixed
rigidity cast to allow gradual weaning
out of cast. At 12 weeks, the fracture
had healed and was clinically clear of
infection.
A binary multivariate analysis was
performed to assess for potential
confounders resulting in higher revision
rates for the IMN cohort (Table 3). The
independent variables that were
statistically associated with revision were
fixation (odds ratio [OR] 0.03, 95% CI
[0.00-0.16], P = .004) and age (OR 0.84,
95% CI [0.72-0.99], P = .02).
Complications, length of hospital stay,
operative time and functional status are
summarized in Table 4. There was no
statistical difference in operative times
between FPT and IMN (mean: 82 vs 78
minutes, respectively). However, patients
treated with FPT had a significantly
shorter postoperative length of hospital
stay (mean: 17 vs 29 days, Mann-Whitney
U test, P = .002). Complications were
seen in 5 of 41 (12%) cases with FPT
compared with 15 of 27 (56%) IMN (P =
.0001). Delayed healing was statistically
more frequent with IMN compared with
FPT (30% vs 10%, P = .03). No significant
difference was seen in rates of superficial
infection between IMN and FPT (4% vs
7%, P = .48). Deep infection was seen in
one case of hindfoot nail and there were
no cases in the FPT cohort. There were
significantly more cases of nonunion in
the IMN cohort compared with FPT (26%
4 Foot & Ankle Specialist Mon XXXX

Table 1.
Patient Demographic Data.

Characteristic FPT (n = 41) IMN (n = 27) P

Gender, n (%)  
 Male 13 (17) 5 (19) .27
 Female 28 (83) 22 (81)  
Age at surgery, y, mean (range) 75.4 (60.4-91.2) 77.4 (60.9-97.4) .40
Fracture pattern, n (%)
 Unimalleolar 7 (17) 0 (0) .07
 Bimalleolar 25 (61) 19 (70)
 Trimalleolar 9 (22) 8 (30)
Fracture dislocation, n (%)
 Yes 22 (54) 14 (52) .88
 No 19 (46) 13 (48)
Open fracture, n (%)
 Yes 6 (15) 7 (26) .25
 No 35 (85) 20 (74)
Isolated injury, n (%)
 Yes 41 (100) 26 (96) .40
 No 0 (0) 1 (4)
Initial Ex-Fix, n (%)
 Yes 7 (17) 9 (33) .08
 No 34 (83) 18 (67)
Comorbidity survival, % (range) 35.2 (0-98) 23.3 (0-98) .10
Smoker, n
 Yes 8 6 .95
 No 25 18

 Unknown 8 7
FRAX score, %, mean (range) 20 (8-58) 19 (5-34) .96
Bone mineral density, mg/cm3, mean (range) 715.7 (587-897) 763.6 (397-1230) .47

Abbreviations: FPT, fibula-pro-tibia; IMN, hindfoot intramedullary nail; FRAX, Fracture Risk Assessment Tool.

vs 0%, P = .001). There was no Preoperative and postoperative mobility in the FPT group compared with the
significant difference in prevalence of are shown in Tables 5 and 6 for FPT and IMN patients 98% versus 81%; however,
prominent screws postfixation (IMN: 19% IMN, respectively. There was a greater this was not statistically significant (P =
vs FPT: 5%, P = .08). proportional return to baseline mobility .33). Follow-up times were longer in the
vol. XX / no. X Foot & Ankle Specialist 5

Table 2.
Lauge-Hansen Classification.

Classification FPT (n = 41) IMN (n = 27)

SAD, n (%) 1 0 (0) 0 (0)
2 1 (2) 2 (7)
SER, n (%) 1 0 (0) 0 (0)
2 0 (0) 0 (0)
3 2 (5) 1 (4)
4 25 (61) 14 (52)
PER, n (%) 1 0 (0) 0 (0)
2 0 (0) 0 (0)
3 4 (10) 4 (15)
4 8 (20) 3 (11)
PAB, n (%) 1 0 (0) 0 (0)
2 0 (0) 2 (7)
3 1 (2) 1 (4)

Abbreviations: FPT, fibula-pro-tibia; IMN, hindfoot intramedullary nail; SAD, supination adduction; SER, supination external rotation; PER, pronation external
rotation; PAB, pronation abduction.

Table 3.
Logistic Regression for Reoperation Rate.

Variable Odds ratio (95% CI) P

Fixation type 0.03 (0.00-0.16) .004**
Age 0.84 (0.72-0.99) .02*
Fracture pattern 5.25 (0.35-78.61) .49
Open fracture 1.00 (0.14-7.38) .99
Initial Ex-Fix 0.21 (0.02-2.19) .19
Charlston Comorbidity Score 1.00 (0.96-1.04) .97
Neuropathy 0.47 (0.50-4.42) .51
*less than 0.05
**less than 0.005

IMN group compared with FPT (mean:
19.9 vs 49.8 months, P = .008).
Discussion
In our aging population osteoporotic
fractures are increasing with the highest
incidence of ankle fractures occurring in
women aged 75 to 84 years old.2,3,14
Low-energy ankle fracture patients,
similar to hip fracture patients, often
have multiple comorbidities, limited
mobility, reduced bone quality and poor
soft tissues making their management
complex. Despite fragility ankle fractures
being commonly seen in practice, they
lack the wealth of research seen in hip
fractures.15 A 2012 Cochrane review
comparing surgical fixation and
conservative management of ankle
fractures in adults concluded there was
6 Foot & Ankle Specialist Mon XXXX

Table 4.
Procedure-Related Outcomes.

Outcome FPT (n = 41) IMN (n = 27) P

Reoperation rate, n (%)
 Yes 2 (5) 12 (44) <.0001**
 No 39 (95) 15 (56)
Surgical time, min, mean (range) 82 (37-142) 78 (46-129) .54
Inpatient stay, days, mean (range) 17 (2-66) 29 (5-111) .02*
Clinic follow up time, weeks, mean (range) 19.9 (5.3-121.1) 49.8 (6.4-217.7) .008*
Complications, n (%)
  Delayed wound healing 4 (10) 8 (30) .03*
  Superficial infection 3 (7) 1 (4) .48
  Deep infection 0 (0) 1 (4) .40
 Nonunion 0 (0) 7 (26) .001**
  Prominent screws 2 (5) 5 (19) .08
  Surgical error 0 (0) 1 (4) .40

Abbreviations: FPT, fibula pro-tibia; IMN, hindfoot intramedullary nail.

Table 5.
Pre- and Postoperative Mobility Following Fibula Pro-Tibia Fixation.a

Preoperative mobility

Postoperative mobility Independent 1× stick Zimmer frame Wheelchair

Independent 15 (37) 0 (0) 0 (0) 0 (0)

1× stick 0 (0) 9 (22) 0 (0) 0 (0)

Zimmer frame 0 (0) 1 (2) 12 (29) 0 (0)

Wheelchair 0 (0) 0 (0) 0 (0) 1 (2)
a
Values are given as n (%).

insufficient evidence to support either
treatment modalities, combining 292
patients from 4 “limited quality” studies.8
The management of fragility ankle
fractures is extremely difficult as
complication rates for both operative
and nonoperative treatment are high.16
In addition, the reported outcomes of
operatively fixed elderly ankle fractures
are poor, with complication rates
reported to be as high as 20%.5,17,18 The
risk factors playing a role in
complication rates include advancing
age, diabetes, multiple comorbidities,
smoking, and dementia.18-20 Despite the
high complication rate, operative
fixation is an established management
while accepting that patients may never
return to full function, regardless of
how their fracture is managed.3,21 In
light of the high complication rates
reported here and elsewhere choosing
the correct operative management
strategy is vital and patients consent
vol. XX / no. X
Table 6.
Pre- and Postoperative mobility Following Hindfoot Intramedullary Nail Fixation.a
Postoperative Mobility Independent
Independent
1× stick
Zimmer frame
Wheelchair
a
Values are given as n (%).
must reflect the poor outcomes in this
cohort.18,21,22
Nonoperative management is not
without complications. Bariteau et al23
reported a 2-fold increase in mortality
with nonoperative management
compared with operative management.
This may have been attributed to the
increased comorbidities in this group,
but regression analysis demonstrated a
protective effect of surgery similar to that
seen with hip fractures.23
The AIM trial was a pragmatic
multicenter study designed to compare
operative fixation and close contact
casting, reporting similar outcomes in
both groups.4 Close contact casing was
applied in theatre under anesthesia, by
surgeons. There were differences in
operating time, complications, and
implant use, but no difference in length
of stay, follow-up visits, or time to
weightbearing between the 2 groups. In
addition, 34 patients were unsuitable for
close contact casting and a further 29
received an alternative treatment, 10
patients required recasting, and 52
required secondary fixation for loss of
position.4 This study excluded diabetics,
open fractures, serious comorbidities,
cognitive impairment, and patients unfit
for anesthesia. Many of our patients fell
into their exclusion group and in our
experience with modern regional
anesthetic techniques surgery can usually
be facilitated in these patients. In
addition, there are other studies with less
favorable results with nonoperative
Preoperative Mobility
1× stick
6 (22) 0 (0)
1 (4) 4 (15)
2 (7) 1 (4)
1 (4) 0 (0)
management reporting non- or malunion
rates of around 50%.6
A recent meta-analysis by Dingemans
et al24 compared different plate fixation
constructs used in osteoporotic ankle
fractures concluding that locking plates
are not statistically superior to
conventional nonlocking plates in terms
of torque to failure or torsional stiffness.
However, the locking plates strength has
been shown to be independent of bone
mineral density, suggesting an advantage
when fixing osteoporotic fractures,
which is also the consensus across
multiple studies.24-27 These findings
suggest that locking plates offer an
advantage in osteoporotic bone.
The results of IMN reported in the
literature are variable. There are a
number of studies reporting that IMN
provide a reliable option in the treatment
of ankle fractures with low complication
and reoperation rates.28 However, other
groups report less reliable results with a
10% implant failure rate, 10% deep
infection rate, and 3% amputation rate.29
This technique remains technically
challenging with frequent complications,
even in experienced hands.30
A recent systemic review by Jordan
et al31 found a range of small-scale
studies with a heterogeneity of implants
for a range primary and salvage
procedures. These studies report a
complication rate between 18% and
22.6% and suggest that intramedullary
implants result in lower functional
outcomes compared with plate fixation.
Foot & Ankle Specialist 7
Zimmer frame Wheelchair
0 (0) 0 (0)
0 (0) 0 (0)
6 (22) 0 (0)
0 (0) 0 (0)
However, to date, there are no
comparative studies available. IMN does
provide an option for fixation of
complex ankle fracture but due to
violation of normal joints postoperative
functional return can be limited and
there is a higher incidence of implant
failure in active patients.10
The criteria for IMN has been
suggested by Amirfeyz et al9 and
Al-Nammari et al32 providing a useful
guide optimize patient selection for IM
nailing in ankle fractures. These authors,
however, reported issues including
backing out of distal locking screws, a
need for screw removal, a case of deep
infection and a below-knee
amputation.9,32
Another issue to consider with IMN is
the risk of a proximal stress riser. This is
of particular concern in osteoporotic
bone with the risk of a periprosthetic
fracture of around 10% reported for short
nails.10,33 Noonan et al34 has shown the
biomechanical benefits using a long IMN.
The results of a long nail have been
reported in high-risk fragility fractures
and have been shown to be comparable
to that of a short nail with lower fracture
risk.32 They do however report a 19%
complication rate and 13% need for
postoperative intensive care unit care.32
Some surgeons have advocated routine
nail removal; however, in one study, 50%
of the patients refused this procedure.35
A recent publication by Karkkola et al36
has reported functional outcomes and
complication rates in a retrospective
8 Foot & Ankle Specialist
cohort of 41 fibula nails in similar
high-risk patients. No wound infections
were seen; however, 4 (10%) patients
required reoperation for malreduction (3)
and displacement of reduction on
mobilization. This complication rate is
comparable to our FPT cohort; however,
fibular nailing may be a concern in frail
patients who struggle to partially bear
weight. A comparative study is required
to compare these 2 treatment options.
The technique of FPT was initially
described by Hahn in 1884 in the
treatment of tibial discontinuity and the
term was later used to describe
techniques used in the treatment of tibial
nonunion and bone loss.37,38 The term
was later used to describe the use of
trans-syndesmotic screws to enhance
fracture fixation by Panchbhavi and in
diabetic fracture management by a
number of authors.11,21,37,39-42 However,
only 1 study by Panchbhavi et al11 has
described technique for the treatment of
16 osteoporotic ankle fractures. This
study reports good outcomes in the FPT
group in terms of complications and
outcome scores. The FPT technique
allows increased purchase in
osteoporotic bone with additional
cortices of fixation and allows for
preservation of the ankle and subtalar
joints. Biomechanical studies have shown
significant differences between standard
and FPT fixation in terms of stiffness,
strength to failure, resistance to rotation,
and deformation.41
This is the largest series of FPT fixation
and the only series comparing it with
IMN. We reiterate that these 2 techniques
are reserved for frail patients with limited
mobility and evidence of osteopenia on
radiographs. There was no significant
difference between the demographics of
our groups on any measure as seen in
Table 1. All our patients had medium or
high FRAX risk scores suggesting that
they had sufficient risk factors to put
them at risk of osteoporosis. In our unit,
high-risk FRAX score patients are started
on osteoporotic treatment without the
need for a DEXA scan. The average
DEXA T-score in patients who were
scanned were within the osteopenic
range. There was no significant
difference in surgical time between these
2 techniques; however, length of stay
was significantly shorter in the FPT
group.
There was a significantly higher
complication rate in the IMN group
compared with the FPT patients, with
delayed wound healing and nonunion
being the most frequent complication in
the IMN cohort. The reoperation rate
also significantly higher in the IMN
cohort with 44% of IMN requiring
complete implant removal. This higher
reoperation rate adds a significant risk to
patients who are already medically frail.
More patients in the FPT group returned
to their preoperative level of mobility
compared with those in the IMN group,
but this difference was not statistically
significant.
We would suggest, based on the
literature and our experience, that there
are multiple issues with IMN fixation for
osteoporotic ankle fractures. This
technique relies on proximal fixation
within the bony isthmus and distal
fixation in the hindfoot. If the bone in
these areas is osteoporotic it provides
little fixation for proximal and distal
screws. Furthermore, none of the screws
are locked into the implant, nor is there
any option for multicortical use, both of
which are key advantages of FPT
fixation. In addition, if the ankle and
subtalar joint are not formally prepared
and firmly compressed, which is usually
the case in trauma and even if attempted
is challenging due to the poor bone
quality, any motion across these areas
can increase the risk of screw loosening
or backing out and proximal fracture.
Last, although nails of different length
are available the distal locking holes
remain in the same position and are not
always in the optimal position due to
patient size, especially if attempting to
use the internal compression option in
the implant.
We accept that this is a retrospective
review and therefore patient selection
may have been prone to bias. We
performed a multivariate analysis,
showing that despite other potential
confounders fixation with FPT does
significantly reduce your risk of revision
Mon XXXX
compared with IMN. Due to the cohort
size (68) we were unable to perform an
extensive multivariate analysis and
therefore we selected the most likely
covariates that would have affected our
revision rate. As a result, the operating
surgeons’ experience was not included
in this analysis as all cases had a trauma
or foot and ankle orthopedic consultant
either performing or scrubbed in theatre
assisting to ensure sound operative
technique. A randomized control trial
would be the next step to conclusively
confirm our findings and rule out any
suggestion of potential bias. We did not
collect patient-reported outcome
measures or functional data, as this was
not available in sufficient detail from
clinical notes. Furthermore, with the
high levels of dementia and mortality in
our cohort functional outcomes and
patient-reported outcome measures
would have been incomplete and
potentially of limited value. Even
without these data we have
demonstrated significant difference
between these 2 techniques. We do not
have long-term follow-up data for these
patients as trauma patients are
discharged promptly once recovered
from initial treatment. We accept some
were lost out of area but we suspect that
if the majority of these patients had
complications they would have returned
to our unit as we are the regional
trauma and limb reconstruction center.
We acknowledge that the results of our
DEXA scans did not show osteoporosis
in all cases. However, we highlight that
all patients had medium-high FRAX
scores. Based on current guidance only
patients with a medium FRAX score
would warrant a DEXA scan and those
with a high score would simply be
treated without a DEXA scan, this may
explain these results.43
In conclusion, this study suggests that
the use of IMN in ankle fractures in
those over 60 years are associated with
longer length of stay, higher complication
and reoperation rates with worse
functional outcomes than FPT. Based on
our results, we suggest FPT provides a
better option for the treatment of these
fractures if the soft tissues permit.
vol. XX / no. X
However, in patients where the soft
tissues are not suitable for direct ankle
fixation then IMN is an alternative option
for surgeons trained and experienced in
its use. This use of IMN however, is a
high-risk option and patients should be
consented accordingly.
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.
Ethical Approval
Not applicable, because this article does
not contain any studies with human or
animal subjects.
Informed Consent
Not applicable, because this article does
not contain any studies with human or
animal subjects.
Trial Registration
Not applicable, because this article does
not contain any clinical trials.
ORCID iDs
Alistair Ian Eyre-Brook https://orcid.
org/0000-0002-8430-7979
Howard Davies https://orcid.
org/0000-0001-9495-5980
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