The Fibula Nail for the Management of Unstable Ankle Fractures

The traditional method of open reduction and internal fixation (ORIF) of ankle fractures has changed very little since the 1960s. Traditional ORIF may lead to complications including wound dehiscence and infection, especially in higher risk patients such as those with diabetes or immunocompromise. Bulky plates in combination with tenuous skin around the lateral malleolus has led to infection rates or wound problems as high as 30 percent in some series.¹ A technique of fibula nailing has been developed that requires minimal incisions around the ankle and much lower profile hardware.² Several studies have supported the use of the fibula nail and have shown complication rates to be lower than traditional ORIF.³

INDICATIONS

Indications for the use of the fibula nail are any displaced ankle fracture that involves the lateral malleolus. We typically do not use if for high Weber C type fractures such as those treated with syndesmotic screws alone. It can also be used for fixation of lateral malleolus fractures with an associated tibial pilon fracture. Currently available fibula nails offer the possibility of placing syndesmotic screws through the nail, which was not possible previously. One must use caution in trimalleolar ankle fractures involving a large posterior fragment, as these patterns tend to do better with direct open posterior plating. In these cases a standard or minifragment plates are used as the surgical approach the fibula has already been performed and the advantage of minimal incisions is no longer beneficial.

PATIENT POSITIONING

Patients are positioned supine on a radiolucent table with a small bump under the greater trochanter to allow easier access to the lateral ankle. A tourniquet is placed but rarely inflated. Once the operative extremity has been prepped and draped, a small stack of towels can be placed under the heel to elevate the ankle to allow easier access for gaining the entry point for the fibula nail.

SURGICAL APPROACHES

A 0.5- to 1.0-cm incision should be made just distal to the tip of the fibula (Fig. 25-1). Blunt dissection can be carried out with a small clamp to avoid injuring the peroneal tendons although they are typically located posterior and distal to the incision. A guidewire is inserted into the distal fibula just at the tip and in midsaggital line of the bone. It is important to check a lateral view to insure the entry point is not too anterior or posterior (Fig. 25-2). A cannulated drill is then passed over the K-wire to open the canal approximately 2 cm in length (Fig. 25-3). Alternatively an awl can be used to establish an entry point (Fig. 25-4).

REDUCTION TECHNIQUES

Percutaneous reduction clamps can be placed around the fracture to hold it reduced before reaming and placing the nail (Fig. 25-5). Once the fracture is reduced the fibula

canal is reamed with a 3.1-mm hand reamer (Fig. 25-6). If there is little resistance using the 3.1-mm reamer, a second 3.6-mm reamer can be used which will allow the use of the larger fibula nail (3.5 mm in diameter).

Figure 25-1. Incision for fibula nail insertion just inferior to tip of lateral malleolus.

Figure 25-2. A: A 1.2-mm K-wire is inserted just at the tip of the lateral malleolus with the aid of intra-op fluoroscopy. B: The lateral view will ensure that the K-wire is in the center of the fibula.

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