Session VII - Foot and Ankle

Lateral Neutralization versus Posterior Antiglide Plating of Closed Distal Fibula Fractures: Results and Outcomes

Mihir M. Patel, MD¹; Sam Akhavan, MD¹; Jung U. Yoo, MD^1,2; Randall E. Marcus, MD^1,2; Brendan M. Patterson, MD^1,3; Heather A. Vallier, MD^1,3;

¹Case Western Reserve University, Cleveland, Ohio, USA;

²University Hospitals of Cleveland, Cleveland, Ohio, USA;

³Metrohealth Medical Center, Cleveland, Ohio, USA

Purpose: We compared results and outcomes for posterior antiglide plates with lateral neutralization plates for the treatment of closed distal fibula fractures.

Displaced lateral malleolus fractures have been traditionally treated with open reduction and internal fixation by using a lateral neutralization (LN) plate with a compression screw. This method has shown excellent union rates but has been associated with reoperation because of hardware prominence. It has been postulated that posterior plating in an antiglide fashion may be mechanically favorable for certain fracture patterns and may lead to less skin irritation but increased peroneal tendon irritation due to the location of the plate. We performed a retrospective review of lateral naturalization and posterior antiglide (PA) plates for treatment of displaced ankle fractures at two university hospital-affiliated institutions.

Methods: Twenty-nine LN and 23 PA plate fixations of distal fibula fractures were performed by four attending surgeons at two university hospital-affiliated institutions. Charts were reviewed to obtain the following data: age at time of surgery, mechanism of injury, time to surgery, time to union, fracture pattern, smoking history, presence of mechanical symptoms up to the last follow-up examination, range of motion, and need for hardware removal. Patients were contacted to obtain Function Foot Index (FFI) scores. The data for rates of reoperation and postoperative symptoms were analyzed by using Fisher's Exact Test, and the results comparing the FFI scores were analyzed by nonparametric means with the Mann-Whitney Test. Ankle range of motion was analyzed with a two-tailed Student's t-test.

Results: Thirteen of 29 patients with LN plates had symptoms related to the hardware starting at 3 months postoperatively compared with 0 of 23 with PA plating (P = 0.0001) after a mean follow-up period of 15.2 months (range, 3 to 72) versus 8.1 months (range, 0.5 to 36). Six of 29 patients with LN plates underwent hardware removal, whereas none of the patients with PA plates required reoperation (P = 0.02). Ankle range of motion at the last follow-up examination was similar for both groups (dorsiflexion, lateral 15.7° ± 5.8° vs. antiglide 17.6° ± 5.4° (P = 0.24); plantarflexion, lateral 29.0° ± 5.2° vs. antiglide 26.4° ± 6.2° (P = 0.12)). The FFI sub-scale scores obtained in the LN group were significantly worse for pain (median, 0.40 vs. 0.06, P = 0.02) but not disability (median, 0.27 vs. 0.09, P = 0.10) or function (median, 0.05 vs. 0.0, P = 0.24) when compared with the PA plate group. In addition, the PA group had significantly better total FFI scores than the LN group (median, 0.69 vs. 0.14, P = 0.03).

Discussion: Although this was a small retrospective study with short follow-up, our results demonstrated that PA plating for distal fibula fractures was associated with significantly lower rates of hardware irritation and hardware removal. In addition, these patients had better total FFI scores and pain sub-scale scores compared with patients who had LN plates.

Conclusion: Posterior antiglide plating of closed displaced distal fibula fractures is associated with significantly lower rates of hardware irritation and re-operation rates for hardware removal. This method is also associated with superior total Foot Function Index scores.