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Nailed it ... Maybe

Some may suggest that there is a paradigm shift from traditional plate and screw (PS) fixation for ankle fractures to intramedullary fibular (IMF) nailing. Intramedullary fixation in the literature includes intramedullary screws, Rush Rods and, more recently, locked cannulated IM nails designed for the fibula anatomy.

Talk track for fibular nailing

1. Earlier time to weight bearing

  • Using a Rush Rod for fibula fixation showed earlier return to weight bearing compared with traditional osteosynthesis (Pritchett et al., 1993).

2. Reduced wound healing and lower rates of reoperation

  • There was a higher reoperation rate in plate fixation (Tas et al., 2019).

  • In a level 1 trauma center, an intramedullary screw group had a statistically significant lower rate of delayed implant removal (8.7% vs. 23.6%) and there was no detectable difference in other measures (McClure et al., 2022).

3. Justifying the cost

  • Economic analysis concluded that if you factor in care for reoperation, the IM nail was more cost effective. But the implant cost for the IM nail was 4.6x higher than traditional plate and screws (White et al., 2016).

The verdict

  • Intramedullary fixation avoids the dreaded lateral incision breakdown.

  • Early evidence indicates that the concern of malunion with IMF may not be as big as expected.

  • What the market could use is a head-to-head between intramedullary screw ($) versus indication specific fibula nails ($$$$).

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