ACFAS 2025 Presentation: Fibular Fractures—Is a Fibular Rod a Viable Option?
With lower complication rates and comparable outcomes to traditional plates and screws, fibular nail fixation is gaining traction, but controversy still remains. At the ACFAS Scientific Conference in Phoenix, AZ, Brian J. Burgess, DPM reviewed the latest data, evolving indications, and key surgical techniques that are having a major impact on foot and ankle surgery.
Transcript:
Brian J. Burgess, DPM: I am Brian Burgess and I'm a podiatrist with Hinsdale Orthopedics, the division of Illinois Bone and Joint Institute.
Consultant360: Can you please detail the key themes of your presentation at ACFAS 2025?
Dr Burgess: One of my presentations is on fibular nail fixation. It's a little bit of a controversial topic in that there are people who are very pro fibular nail usage, and there's also a spectrum of people who are kind of against fibular nail fixation for a variety of reasons. So some of my key points that I'll be talking about at this meeting, number one is some tips and pearls in order to get anatomic reduction or perfect reduction with our fibular nails. That's a common talking point. Number two, we're going to review some of the literature as it pertains to number one, patient reported outcomes. And number two, in terms of complications.
So there's been a fair amount of publications, especially within the last 5 and 10 years, looking at outcomes for fibular nails. And the literature is all in agreement where number one, complication rates are significantly lower with use of fibular nails as opposed to standard plate fixation. And number two, our outcomes are pretty similar. Our patient-reported outcomes at 1 year are very similar to plate fixation. So what that tells us is that patients are doing just as well with fibular nails as they are with traditional plates and screws. With the main difference being lower complication rates.
C360: Why is this topic particularly relevant right now?
Dr Burgess: Since the last 10 years, the use of fibular nails has increased pretty significantly. So it is a newer technology. We are making some significant advancements in terms of instrumentation. And because it is somewhat newer, our indications are changing and becoming more well-defined. And more and more people are becoming interested in fibular nailing because they are starting to see it more, whether it's at meetings like the ACFAS, whether it's on social media or just word of mouth. So the number of cases is growing, the number of publications is certainly growing, and it's starting to become accepted in terms of a recommended treatment for ankle fractures.
C360: Can you share some of your insights on the pros and cons of rod fixation for fibular fractures, and if there are any specific clinical scenarios where you feel a rod would be superior?
Dr Burgess: Yeah, certainly in terms of fibular nails, what we're really competing with is our traditional plates and screws. That's how a lot of people were trained. If you have a fibular fracture, the standard of care is a big incision, large dissection, a lot of soft tissue injury in order to put a large plate and screws across that fracture. And so with some of the older generation fibular nails, if we talk like generation one fibular nails for example, there were some things with those initial devices that just lent to very poor outcomes. We had poor reductions, we had poor outcomes. And I think a lot of people are still kind of stuck on that data from 15 years ago where they're convinced that we cannot get good reduction with fibular nails. But again, our indications have changed, our implants have changed. Industry has definitely had a role in designing better implants with use of surgeon input.
And now that we have better implants and better fixation, I think that some of that controversy is changing. But probably the biggest talking point for those that are opposed to fibular nails is really as it pertains to reduction in our ability to get solid reduction. In terms of indications, like you mentioned, it's kind of twofold. Initially when these fibular nails came out, or at least our second and third generation fibular nails came out 10 years ago, the main talking points and indications were these high risk patients where we have patients who have diabetes, they're elderly, they have poor soft tissue conditions, and that's what people were initially using fibular nails for. They were trying to just do something for the fracture but limit the surgical footprint. And I think in the last couple of years, because we've gained more confidence with fibular nails, I think that our indications have changed. So for me, at least one of my indications for fibular nails, and I think it's the best indication out there, is a pretty simple straightforward fibular fracture. So almost the complete opposite end of the spectrum is what we initially thought, and that was your trainwreck diabetic smoker. But for me, if it's a simple fibular fracture, we know the patient's going to do pretty darn well, regardless of if we fix 'em or not. If we can minimize surgical footprint, if we can minimize complications, I think we're doing a service for our patients.
C360: What are the most important takeaways from your presentation?
Dr Burgess: Yeah, I think some of the biggest takeaways, number one, its usage is growing. Number two, there is a lot of pretty decent literature that supports its use. So it's not something that we should continue to view as experimental or anything along those lines. It really is gaining acceptance in the podiatry community, the orthopedic community, and even the trauma community.
C360: Are there any gaps in our knowledge that you detail in your presentation?
Dr Burgess: Yeah, I'm going to present a study that we did that we haven't published yet, but are looking into publishing, where we really look at the intramedullary anatomy of the fibular canal as it pertains to fibular nails. There's some certain nuances like the fibular isus and the diameters at different levels within the fibular canal that really are important to that. Clinicians should be aware of when deciding, number one, which implant to use, and number two, which diameter or length implant to use. So we are going to give some advice there based off a recent CT study that we did.