Percutaneous Reduction and Provisional Pinning of the Distal Fibula: A Novel Way to Maintain Fibular Length in Temporary Stabilization

Abstract

Summary:

Ankle fractures are commonly observed by orthopaedic trauma surgeons, foot and ankle surgeons, and general orthopaedists with more than 135,000 fractures surgically treated every year in the United States.¹ The soft tissue envelope surrounding the osseous anatomy of the ankle is limited and many injuries, including those that result from higher injury mechanisms and/or those occurring in hosts with vascular and metabolic comorbidities may benefit from a delay in definitive fixation; this may minimize risks of wound healing issues and fracture-related infection.^2,3 Open fractures may benefit from temporizing fixation after debridement and irrigation for the same reasons.^4–6

The benefits of temporizing external fixation in pilon fractures has been recognized for decades.⁷ The use of ankle-spanning external fixation for ankle fractures and dislocations has become more frequently used to maintain coronal and sagittal alignment of the ankle mortise as a bridge to definitive fixation.^8–10

However, standard ankle-spanning external fixation techniques do not always directly restore fibular length and rotation, especially in fracture patterns with syndesmotic disruption and/or segmental fibular comminution. Some authors have advocated for limited internal fixation of fibula fractures at time of external fixation application to address this problem,⁷ but this still necessitates a surgical approach through a traumatized soft tissue envelope and potentially compromises posterolateral and anterolateral approaches that could be used to address associated Volkman or Chaput fragments. Delayed distal fibular open reduction and internal fixation of shortened fractures has frustrated orthopaedic surgeons for decades and techniques such as “push–pull” screws¹¹ and extensive soft tissue dissection¹² are often necessary to restore anatomic fibular reduction of length and rotation. Given these challenges, the senior author began to use a technique of percutaneous reduction and buried provisional pinning of the distal fibula to the talus for fibula fractures with persistent shortening after ankle-spanning external fixation of injuries not deemed appropriate for immediate open reduction and internal fixation. We aim to report early results and describe this novel, low-cost surgical technique.