|Year : 2014 | Volume
| Issue : 1 | Page : 17-23
Results of percutaneous rush pin fixation in distal third fibular fracture: A retrospective study
Ramji Lal Sahu
Department of Orthopedics, SMS and RI, Sharda University, Greater Noida, Uttar Pradesh, India
|Date of Web Publication||26-Aug-2014|
Ramji Lal Sahu
11284, Laj building, number 1, Doriwalan, New Rohtak Road, Karol Bagh, New-Delhi
Source of Support: None, Conflict of Interest: None
Aims: Aim of this retrospective study is to evaluate the results of percutaneous rush pin fixation in distal third fibular fractures.
Settings and Design: Retrospective study.
Materials and Methods: This study was conducted in the Department of Orthopedic Surgery in M. M. Medical College from July 2006 to November 2010. Seventy-eight patients were recruited from emergency and outpatient department, having closed fracture of distal third fibula. Postoperatively all the patients were functionally evaluated as per Kristenson's criteria and the Weber's criteria which included objective criteria, subjective criteria, and radiological evaluation at 3, 6, and 12 months after the surgery.
Results: Out of seventy-eight patients, 69 patients underwent union in 90-150 days with a mean of 110.68 days. Touch down weight bearing was started on 2 nd postoperative day. Complications found in four patients who had nonunion, and ﬁve patients had delayed union which was treated with bone graft. The results were excellent in 88.46% and good in 6.41% patients.
Conclusions: I conclude that the fixation using rush pin in distal third fibular fracture is a safe and effective method of surgery that could be performed easily as well as minimal soft tissue disruption and did not require secondary surgery to remove the wire, and showed sufficient stability after fixation. Therefore, closed reduction and internal fixation with rush rods is one of the good treatment modalities of distal fibular fracture.
Keywords: Fibular fracture, morbidity, percutaneous, rush pin
|How to cite this article:|
Sahu RL. Results of percutaneous rush pin fixation in distal third fibular fracture: A retrospective study. Afr J Trauma 2014;3:17-23
| Introduction|| |
Ankle fractures comprise 9% of all fractures and their incidence is increasing, particularly among elderly women. ,, The procedure of plating the lateral malleolus has changed little since the 1960s and has a complication rate of up to 30%.  Wound infection has been seen in up to 26%, symptoms related to the metalwork in up to 50%, and mechanical failure in 14%. ,, Higher rates of complications are seen in the elderly and in those with diabetes or neuropathy. , The rush nail is an alternative method of fixing the lateral malleolus. It requires a smaller incision (1 cm compared with 8 cm for lateral plating) and less soft-tissue dissection. , It affords better mechanical stability in osteoporotic bone with less prominent metalwork, and has the potential to reduce the incidence of complications.  Favorable short-term outcomes of rush nailing have been reported in small numbers of patients. ,, A study of 37 patients had encouraging results with a mean Olerud and Molander Score (OMS) of 87, a good radiological outcome in 97%, and a low complication rate; with only one case of loss of fixation and two of infection.  The purpose of this study was to evaluate our experience of treating unstable lateral malleolar fractures with a rush nail and to assess the outcome of this method of treatment.
| Materials and Methods|| |
This retrospective study was carried out at Orthopedics Department of M. M. Medical College from July 2006 to November 2010. It was approved by institutional medical ethics committee. A total of 78 patients with fracture lateral malleolus admitted to our institute were included in present study. A written informed consent was obtained from all the patients; they were explained about treatment plan, cost of operation, and hospital stay after surgery, and complications of anesthesia. They were followed-up after surgery, were clinically and radiologically assessed for fracture healing, joint movements, and implant failure. According to the criteria the results are graded as excellent when the fractures unites within 16 weeks without any complication, good when union occur within 24 weeks with treatable complications like superﬁcial infection and ankle stiffness and poor when union occur before or after 24 weeks with one or more permanent complications like infection (osteomyelitis), implant failure, nonunion, limb shortening and permanent ankle stiffness. Delayed union was recorded when the fracture united between 3 and 6 months, while nonunion was noted when union had not occurred after 8 months of treatment. Follow-up was done. Patients with closed lateral malleolus fracture with age more than 16 years and presented within a week of the injury and did not have any previous surgical treatment for the fracture were included in the study. Malnourished patients and those with open fractures, pathological fractures (except osteoporosis), and fracture nonunion were excluded from the study. Examination of patients was done thoroughly at the time of admission to exclude other injuries. In majority of the patients close rush nailing of the lateral malleolus was performed on 7 th -14 th day after the injury. Fractures of the ankle were evaluated using plain radiographs in anteroposterior (A-P), lateral and mortise views. The fractures were classified using the Lauge-Hansen,  Weber's,  and AO/OTA classification systems; and graded as per Kristenson's criteria  and by the number of malleoli involved. Instability of the syndesmosis was identified on the basis of the mechanism of injury and the fracture pattern. Pain elicited with the squeeze test (manual medial-lateral compression across the syndesmosis) and the external rotation stress test was considered as indicative of clinical syndesmotic instability. Radiologically tibiofibular clear space of less than 5 mm and widening of the medial clear space of more than 4 mm were considered as indications of syndesmotic instability. Intraoperatively, the fibula was manipulated to determine if there was excessive lateral displacement indicating syndesmotic injury. In this study, operative fixation of the syndesmosis was done for fractures in which the disruption of the syndesmosis exceeded 3 mm, when medial stabilization could not otherwise be obtained and when of widening of the syndesmosis is made when there is a space of more than 5 mm between the distal aspects of the tibia and the fibula, as seen on the mortise radiograph. A 4.5 mm screw was placed from the fibula medially into the tibia engaging three cortices. Removal of the screw was done at 6 weeks postoperatively for all cases.
The patient is placed supine on a radiolucent table. A bump is placed underneath the ipsilateral hip to prevent the usual external rotation of the limb and to provide access to the lateral side of the ankle. The entire limb is prepared and draped. The starting point for the rush nail is the distal tip of the fibula. A small (approximately 2 cm) longitudinal incision is made approximately 2-3 cm distal to the tip of the fibula; it should be distal enough to allow the drill bit to drill in line with the fibular shaft. A sharp elevator clears the soft tissue at the tip of the fibula to create a "landing zone" for the drill bit. With the help of an image intensifier, a 3.5 mm bit is used to drill an opening hole in the distal fibula. It is essential to drill in line with the diaphysis of the fibula on both A-P and lateral images to facilitate passage of the rush nail. After the opening hole is made, a long 2.5 mm drill bit is used to "ream" the distal fibula to approximately 5-6 cm. A soft-tissue sleeve for the 2.5 mm drill bit is inserted into the previously drilled starting hole. It is essential to avoid drilling through the cortex, while the drill is being advanced proximally. It is also important to avoid drilling into the medial cortex while the drill is being advanced, as the rush nail follows the drill path and becomes incarcerated in this cortical window. A 2.4 mm rush nail is locked securely onto the T-handle chuck. The nail is then placed into the starting hole distally and advanced proximally with controlled mallet strikes on the chuck. Rush nail can be controlled with a T-handle chuck, "choking up" on the nail and resetting the chuck farther back as the nail is advanced into the fibula. There should be minimal resistance with nail insertion, and the T-handle should be rotated in 45± motions while the mallet is used. At the fracture site, the nail is advanced across the fracture and into the proximal fragment medullary canal. A closed reduction technique, such as axial traction or blunt manipulation of the fracture fragments, can be used to pass the rush nail. The nail is advanced 5-10 cm into the fibular medullary canal in the proximal fragment. The distal end of the bend nail is then impacted into the lateral malleolus. The wound is then irrigated and closed with nylon sutures. Rehabilitation such as touch down weight bearing was started on 2 nd postoperative day and sutures were removed on 14 th postoperative day. These patients were assessed clinically and radiologically for union timing at 12 months following surgery. Patients were assessed for delayed union (more than 4-6 weeks postoperative) and nonunion  (9 months following surgery). Statistical analysis was limited to calculation of percentage of patients who had unions, malunions, delayed unions, or nonunions and excellent, good, fair, and poor outcomes. The final result was graded as excellent, good, fair, or poor as using assessment criteria.
Excellent No pain
Complete range of active and passive movement
Minimal pain noted only after walking for unaccustomed distance
Active and passive dorsiflexion, plantar flexion ROM two-third of normal ankle
Pain moderately incapacitating, no stick or other walking aid used, reduced with analgesics
All movement at ankle painless, and ROM two-third and of normal ankle. No tenderness.
Pain severe requiring cane or brace and daily analgesics, hindering work
Movement at ankle is painful and ROM less than one-third of normal ankle or stiff ankle
Tenderness at fracture site
Deformity at ankle joint.
| Results|| |
There were 78 patients in this study, 65 (83.33%) patients were male and 13 (16.66%) patients were females. The patients were divided in three groups according to their age for simplicity. Young age group included those patients whose age was less than 40 years. In this group there were seven females and 45 males. Middle age group included patients, who were between the ages of 40 and 60 years. This group included five females and 15 males. Old age group included patients older than 60 years. This group consisted of one female and five males [Table 1]. Five patients were diabetics and four of them were taking insulin. One female patient was diabetic and was taking oral hypoglycemic. Twenty-one cases (most of them in older age group) affected were due to twisting injury, 42 cases due to road traffic accident, three cases were due to fall from height and 12 cases were due to sports injuries [Table 2]. Forty-seven cases of lateral malleolar fractures were found on the right side and 31 cases were seen on the left side of ankle joint [Table 3]. The fractures were classified according to the Lauge-Hansen and Weber's classifications  and graded as per Kristenson's criteria. There were 17 cases of supination-adduction injury, 30 cases of supination-external rotation injury, two cases of pronation-abduction injury, 27 case of pronation-external rotation injury, and two cases of pronation-dorsiflexion injury. There were 17 cases of type A, 30 cases of type B, and 31 cases of type C Weber injury [Table 4] and [Table 5]. There were seven cases (8.97) with associated fractures. All were in operative group and had humerus, femoral shaft, medial malleolus fractures, tibia shaft fracture, and stable compression vertebral fractures. One patient had concussion head injury and three patients had lacerated wounds. All closed lateral malleolar fracture were treated percutaneous intramedullary fixation with rush nails after close reduction. Medial malleolus was fixed with tension band wiring (17 cases) and malleolar screw (61 cases). Fracture shaft of tibia were fixed with interlocking nails and plating [Figure 1]a and b, [Figure 2]a and b, [Figure 3]a and b, [Figure 4]a and b. Syndesmotic screw was used in 14 cases: The clinical results of our study were rated on the basis of the criteria of union, nonunion,  delayed union, or malunion. The patients were followed according to their clinical status. Sixty-nine patients had union in 90-150 days with a mean of 110.68. Ten of our patients had diabetes. Union was achieved in eight patients in 95-109 days with a mean of 103.38. Rehabilitation: We allowed our patients to start touch down walking with crutches on the 2 nd day of operation as they feel comfortable. All patients, except two, started partial weight bearing on the 6 th week and full weight bearing on the 12 th week. These two patients had non-weight bearing ambulation till the callus became visible on radiographs. They had comminution at fracture site. All of our patients had full range of motion of their ankles. Three patients out of seventy-eight complained postoperative ankle pain, which was spontaneously resolved in 2 weeks. There were five, that is, 6.41% delayed unions which were treated by bone grafting. In our study only four of our patients (5.12%) was labeled as nonunion and was treated by bone graft. No rotational instability was seen in any patients postoperatively and after follow-up of 1 year. Postoperatively all the patients were evaluated as per Kristenson's criteria.  80.76% of patients had good results, 14.10% had fair results, and 5.12 had poor results [Table 6] and [Table 7]. The cases after discharge were followed-up at 2 weeks, 6 weeks, 3 months, and 6 months and at the end of 1 year regularly. One case had a discharge from the incision site over the medial malleolus after 1 month which showed no evidence of deep infection. The wound healed over a time of 1 month without any further complications. No cases of degenerative arthritis were noted in patients. The patients were evaluated as per the rating of the Weber's criteria  which included objective criteria, subjective criteria, and radiological evaluation [Table 8]. In subjective evaluation, 71.79% patients had good results, 23.07% had fair, and 5.12% had poor results. In objective evaluation, 74.35% patients had good results, 21.79% had fair and 3.84% had poor results. In radiological evaluation, 80.76% patients had good results, 14.10% had fair, and 5.12% had poor results.
|Table 4: Depicting incidence of fractures depending on the mechanism of injury (N = 78)|
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|Table 5: Depicts radiological types depending on Weber's classification (N = 78)|
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|Table 6: Depicts preoperative radiological grading of fractures (N = 78)|
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|Table 8: Depicts the percentage of the results based on Weber's criteria (N = 78)|
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|Figure 1: (a) Preoperative anteroposterior (A-P) and lateral view of fracture of lower one-third of tibia and fibula (Weber C type). (b) Postoperative A-P and lateral view of ankle joint and shaft of tibia and fibula. Supramalleolar fracture fixation of fibula with rush nail and fixation of tibia with cobra plate|
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|Figure 2: (a) Preoperative A - P and lateral view of fracture of bimalleolar fracture of ankle joint (Weber B type). (b) Postoperative A - P and lateral view of ankle joint and shaft of tibia and fibula. Syndesmotic fracture fixation of fibula with rush nail and fixation of medial malleolus with two cannulated cancellous screw|
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|Figure 3: (a) Preoperative A - P and lateral view of fracture of midshaft of tibia and fibula (Weber C type). (b) Postoperative A - P and lateral view of ankle joint and shaft of tibia and fibula. Supramalleolar fracture fixation of fibula with rush nail and fixation of tibia with interlocking nail|
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|Figure 4: (a) Preoperative A - P and lateral view of fracture of lower one - third of tibia and fibula (Weber C type). (b) Postoperative A - P and lateral view of ankle joint and shaft of tibia and fibula. Supramalleolar fracture fixation of fibula with rush nail and fixation of tibia with cobra plate|
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| Discussion|| |
The current thinking of fixation of fracture fibula is that in ankle fractures the medial side injury is more important than the lateral side injury. If there is no medial malleolar fracture or no deltoid injury and the talus is centred, there is no need to fix the fibula. Therefore, if the associated lateral malleolar fracture, in pilon fractures, is reduced satisfactorily and is congruous with the ankle joint, need not be fixed for minor fibula displacement. The other optim is that K-wire or a rush rod is inserted in the intramedullary canal of the fibula through the tip of the lateral malleolus. Dilemma of the fibular fixation: Fibula fixation is controversial. If the fibular fixation is fixed with plating, it prevents collapse of the comminuted metaphyseal area or gap, resulting in nonunion or malunion with deformity. If the fibular fracture is not fixed, the ankle mortise may not be congruous, because if not fixed lateral malleolus may get displaced. If the fibula is fixed, bone grafting is mandatory if there is comminuted or gap. If the ankle mortise is anatomically reduced by ligamentotaxis fibula need not be fixed with plating. A rush rod, K-wires, or intramedullary nail is suggested. Potential advantages of fibular fixation include mechanical stability, assisting in reduction of the anterolateral (chaput) articular fragment, and restoring the length and alignment of the fibula. While such a construct cannot control rotation, it can preserve length as well as prevent varus and valgus displacement. In my study, all the fibular fractures were fixed with rush rods and did not see any rotational instability. There were 17 cases of type A, 30 cases of type B, and 31 cases of type C Weber injury. Fractures of the ankle comprise 9% of all fractures and their incidence is increasing, particularly among elderly women. ,, The technique of plating the lateral malleolus has changed little since the 1960s and has a complication rate of up to 30%.  Wound infection has been seen in up to 26%, symptoms related to the metalwork in up to 50%, and mechanical failure in 14%. ,, Even higher rates of complications are seen in the elderly and in those with diabetes or neuropathy. , The fibular nail is an alternative method of fixing the lateral malleolus. It requires a smaller incision (1 cm compared with 8 cm for lateral plating) and less soft-tissue dissection. , It affords better mechanical stability in osteoporotic bone with less prominent metalwork, and has the potential to reduce the incidence of complications.  Favorable short-term outcomes of fibular nailing have been reported in small numbers of patients. ,, A study of 37 patients had encouraging results with a mean OMS of 87, a good radiological outcome in 97% and a low complication rate, with only one case of loss of fixation and two of infection.  Bugler  reviewed the results of 105 patients with unstable fractures of the ankle using the acumed fibular nail. The mean age of the patients was 64.8 years (22-95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (four of six). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Some authors claim that the differential pitch of the screw resulted in compression at the fracture site.  But considering that it is inserted into the medullary cavity, the 6.5-mm Acutrak screw may not have a purchase in the distal fibula (at the entry point) if the fibula is wider, as may be the case in some patients, leading to rotational instability. Moreover there may be a serious risk of splintering the lower end of fibula if such fixation is used in patients where the lower end is not wide enough to accommodate a 6.5 mm screw. An intramedullary fixation in long oblique fractures will lead to translation of the fracture in either plane depending on the plane of obliquity. Another issue is regarding need for implant removal after fixation. They anticipate technical difficulty if implant removal is contemplated, considering the new bone formation that would occur at the screw insertion site due to burying of the screw head. They expect need for more dissection and potential bone and ligament damage during implant removal, if this became necessary. Unstable ankle fractures are most commonly treated by open reduction and internal fixation (ORIF) using techniques that have not changed significantly for many years and have a high rate of complications, particularly in osteoporotic bone. Metalwork and scarring can be troublesome and require secondary surgery. The complication rate following ORIF in the elderly is up to 40%.  It is also considerably higher in patients with systemic disease, particularly diabetes and neuropathy and in those with compromised local soft tissues and those who smoke. , A proportion of those patients who avoid initial complications will later require removal of metalwork. ,, Suggested alternatives to traditional lateral plating techniques include the use of locking plates and minimally invasive plating techniques. Although locking plates have been shown to be biomechanically advantageous in osteoporotic bone this benefit may be negated by a higher rate of wound complications. , Minimally invasive plating techniques allow surgery to be carried out through marginally smaller wounds (3-4 cm in a recent report  ) but are more technically challenging than traditional techniques.  Intramedullary fixation of the fibula minimizes dissection. Successful results have been reported for a variety of implants, including the Rush nail and other types of fibular nail. ,, Two groups have reported their results using the Biomet SST fibular nail (Biomet Inc., Warsaw, Indiana), an intramedullary nail that is fixed to bone with a distal A-P locking screw only. , In total, they report 35 patients with good functional and radiological results. However, this nail does not allow for placement of a screw across the syndesmosis, and Ramasamy and Sherry reported failure of fixation with lateral talar subluxation in one patient (9%).  Rajeev et al., 14 do not report any cases of failure of fixation but the postoperative radiograph included does show evidence of talar shift. In a randomized clinical trial involving 50 elderly patients, Pritchett compared treating geriatric ankle fractures with intramedullary rush rods compared to standard plates and screws.  The authors found that 88% of the patients managed with rush rods had a good or fair functional result at follow-up compared to 76% of those treated with plate fixation. In addition, patients in the rush rod treatment group were able to resume full weight bearing 6 weeks earlier than those in the plate and screws cohort. In another study, it was found that 80.76% of patients managed with rush rods had good results and 14.10% had fair functional results as per Kristenson's criteria.  The patients were evaluated as per the rating of the Weber's criteria  which included objective criteria, subjective criteria, and radiological evaluation [Table 8]. In subjective evaluation, 71.79% patients had good results, 23.07% had fair and 5.12% had poor results. In objective evaluation, 74.35% patients had good results, 21.79% had fair, and 3.84% had poor results. In radiological evaluation, 80.76% patients had good results, 14.10% had fair, and 5.12% had poor results. Patient reported outcome measures also suggest a satisfactory subjective outcome: The psychological domain score of the normalized SF-12 was slightly better than the population mean (53.1 (26.7 to 66.3) vs 50.0), and the mean physical function score was only slightly less than that of the healthy population (41.5 (17.7-60.6) vs 50.0). These are comparable with the results reported by Shah et al.,  of 85 ankle fractures in patients with a much younger mean age of 50 years treated with lateral plating augmented with lag screw fixation, who had a mean psychological domain score of 49.9 and a physical score of 45.6. The mean abbreviated Olerud and Molander joint-specific scores (62.2 for the entire cohort) were also comparable to those reported for similar patient groups. Yang et al.,  reported a mean score of 61 in patients aged > 50 years within their cohort of supination external rotation Lauge-Hansen grade IV  ankle fractures. The mean American Academy of Orthopedic Surgeons/American Association of Orthopedic Surgeons (AAOS) score for patients treated by the current technique was 82.5. This is within 1 standard deviation (SD) of the mean score for a healthy population (mean 93.2 (SD 12.3)) and comparable to results found in other cohorts of patients sustaining ankle fractures.  Bois and Dust  in their cohort of 17 patients with posterior malleolar fractures, found a mean score of 87, and Gardner et al.,  found a mean score of 79 at a follow-up of 8 months in another cohort of patients with posterior malleolar fractures and a mean age of 45 years. Ali et al.,  reviewed seven patients, had ankle fracture with fragile or damaged skin. All operated within 10 days of injury, including those who were on warfarin or significant medical problems. All underwent closed reduction and or percutaneous medial malleolar fixation and stabilization of the lateral column with Rush pin through a stab incision under X-ray control. A lightweight plaster was applied for 4-6 weeks. All fracture healed in an acceptable position without any skin complication. One patient who had preoperative ulcer also healed. In my study, all closed lateral malleolar fracture were treated percutaneous intramedullary fixation with rush nails after close reduction. Medial malleolus was fixed with tension band wiring (17 cases) and malleolar screw (61 cases). Syndesmotic screw was used in 14 cases: The clinical results of our study were rated on the basis of the criteria of union, nonunion,  delayed union, or malunion. The patients were followed according to their clinical status. Sixty-nine patients had union in 90-150 days with a mean of 110.68. Ten of our patients had diabetes. Union was achieved in eight patients in 95-109 days with a mean of 103.38.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]