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  • Author: Andreas Frodl x
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Andreas Frodl Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

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Benjamin Erdle Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

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Hagen Schmal Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany
University Hospital Odense, Dep. Of Orthopedic Surgery, Sdr. Boulevard 29, 5000 Odense C, Denmark

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  • Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation – all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions.

  • We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients.

  • A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29–0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76–2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21–2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups.

  • Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually.

Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003

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Andreas Frodl Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

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Johannes Hauss Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

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Andreas Fuchs Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

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Markus Siegel Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

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Hagen Schmal Department of Orthopedic Surgery, University Hospital Odense, Odense, Denmark

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Jan Kühle Department of Orthopedics and Traumatology, Freiburg University Hospital, Freiburg, Germany

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Purpose

  • The fixation method of distal, extra-articular femur fractures is a controversially discussed. To ensure better stability itself, earlier mobilization and to prevent blood loss – all these are justifications for addressing the femur via reamed intramedullary nailing (RIMN). Anatomical reposition of multifragmentary fractures followed by increased risks of non-union are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of non-union and wound infection, as well as blood loss and time of surgery.

Methods

  • According to the PRISMA guidelines we conducted this systematic review by searching the Cochrane, PubMed, Ovid, MedLine, and Embase databases. Inclusion criteria were the modified Coleman methodology score (mCMS) >60, age >18 years, and extra-articular fractures of the distal femur. Biomechanical and animal studies were excluded. By referring to title and abstract relevant articles were reviewed independently. In the consecutive meta-analysis, we compared 9 studies and 639 patients.

Results

  • There is no statistically significant difference comparing superficial wound infections when RIMN was performed (OR = 0.50; 95% CI: 0.18 – 1.42; P = 0.19) as well as in deep wound infections (OR = 0.74; 95% CI: 0.19–2.81; P = 0.62). However, these results were not significant. We also calculated for potential differences in the rate of non-unions depending on the surgical treatment applied. Data of 556 patients revealed an overall number of 43 non-unions. There was no significant difference in rate of non-unions between both groups (OR = 0.97; 95% CI: 0.51–1.85; P = 0.92).

Conclusion

  • No statistical difference was found in our study among RIMN and plate fixation in the treatment of distal femoral fractures with regard to the incidence of non-union and wound infections. Therefore, the indication for RIMN or plating should be made individually and based on the surgeon’s experience.

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