Minimally Invasive Intramedullary Fixation vs Plate Fixation of Distal Fibular Fractures in Elderly Patients: A Natural Experiment

Background: The aim of this study was to compare the postoperative complications and functional outcomes of intramedullary fixation (IMF) and conventional plate fixation (PF) for Lauge-Hansen supination external rotation type 4 fractures in patients aged 70 years or older. Methods: This natural experiment involved 2 hospitals (A and B) in a single trauma region. Between June 2019 and January 2023, a total of 80 patients aged 70 years or older with an unstable supination external rotation type 4 fracture were treated with either a geriatric treatment pathway consisting of early-stage IMF following immediate protected full weight bearing in hospital A (n = 48) or PF using a one-third tubular locking plate in hospital B (n = 32). The primary outcome was the total number of postoperative complications during 12 months of follow-up. Results: The IMF group had a higher mean age compared with the PF group (79.8 vs 75.7 years, p < .001). The total number of postoperative complications was lower in the IMF group compared with the PF group (27% vs 58%, p = .030). Wound infections were observed less frequently following IMF compared to PF (15% vs 35%, p = .031), with infection treatment involving no implant removal in the IMF group (0/7 for IMF vs 4/11 for PF). Intramedullary fixation resulted in better functional outcome measured by the Olerud-Molander Ankle Score (p = .040) and less postoperative pain (p < .001) compared to PF, with the greatest relative differences observed at 6 weeks postoperatively. Conclusion: Intramedullary fixation resulted in significantly less postoperative complications and better functional outcome compared to PF, despite the higher mean age of patients in the IMF group. A geriatric treatment pathway using an intramedullary nailing technique may be preferred over conventional PF in an elderly population, especially in case of patient obesity or compromised general health status.