Intramedullary fibular nailing versus open reduction internal fixation for unstable geriatric ankle fractures: A systematic review and meta-analysis

Mckenzie D. Brandt; Vraj Amin; Samuel Hovland; Quintin Norris; Lisa K. Cannada

doi:10.1016/j.jor.2025.10.018

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72 (); 160-172

doi:

10.1016/j.jor.2025.10.018

Intramedullary fibular nailing versus open reduction internal fixation for unstable geriatric ankle fractures: A systematic review and meta-analysis

Mckenzie D. Brandt^a,, Vraj Amin^a, Samuel Hovland^a, Quintin Norris^b, Lisa K. Cannada^c

a College of Medicine, University of Central Florida, Orlando, FL, USA

b Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Tampa, FL, USA

c University of North Carolina SOM, Charlotte Campus, Novant Health Fracture Clinic, Charlotte, NC, USA

⁎Corresponding author: Mckenzie D. Brandt. mc417656@ucf.edu

Received: 2025-8-24, Accepted: 2025-10-26, Published: 2025-10-28

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Surgical fixation of ankle fragility fractures presents unique challenges in the elderly. Although the standard fixation technique is open reduction internal fixation (ORIF), intramedullary fibular nailing (IMFN) offers a minimally invasive approach. In this systematic review and meta-analysis, we compare postoperative complication and reintervention rates in geriatric ankle fractures fixed with IMFN versus ORIF.

A systematic review was conducted in MEDLINE (PubMed), Web of Science, EMBASE, Academic Search Premier, ProQuest, Google Scholar, Clinicaltrials.gov, and Cochrane Library to identify studies reporting postoperative outcomes in geriatric ankle fractures fixed with IMFN. Studies which compared postoperative outcomes to ORIF were subject to a quantitative meta-analysis.

Thirteen studies were eligible for inclusion with a mean age >65 years. In a pooled analysis of 421 fibular nails, the overall rates of postoperative wound infection, malunion or nonunion, and revision were <5 %. A meta-analysis of five comparative studies revealed no significant difference in the rate of revision, malunion or nonunion, symptomatic hardware, hardware removal, or thrombosis between IMFN (n = 161) and ORIF (n = 374). However, the rate of postoperative wound infections was significantly lower in the IMFN group (RR = 0.34; CI: [0.15, 0.74]; p = 0.007). A subgroup analysis revealed that only the risk of superficial wound infections, and not deep wound infections, was significantly decreased.

IMFN is a promising avenue for geriatric ankle fracture fixation and should be considered within the context of individualized patient care plans, particularly in patients at an increased risk of infection.

Keywords

Ankle fracture

Fibular nail

Intramedullary fixation

Elderly

Orthopedic trauma

Postoperative complications

Show Related Articles from PubMed

1 Introduction

Ankle fragility fractures are an increasingly common cause of orthopedic injury in the elderly which require complex medical management.¹ Advanced age is associated with a greater comorbidity burden, poor bone quality and wound healing, and mobility limitations, each of which are barriers to an uneventful recovery.²^,³ Although surgical fixation has been shown to reduce the risk of malunion and mortality compared to non-operative management,^4–6 perioperative and postoperative complication rates remain high. The one-year mortality rate following acute ankle fracture approaches 12 % in the elderly,⁷ and outcomes in patients who have open fractures or are >80 years of age are particularly poor.⁸^,⁹

While open reduction internal fixation (ORIF) is considered the gold standard fixation technique for unstable ankle fractures, intramedullary fibular nailing (IMFN) is an alternative surgical fixation technique that is minimally invasive and offers an expedited return to weight-bearing activity.¹⁰ IMFN fixation has demonstrated equivalent¹¹ or superior¹⁰ biomechanical strength compared to ORIF and is associated with relatively low complication rates,¹²^,¹³ particularly in those at increased risk of infection.¹⁴

While previous reviews have discussed the use of IMFN in the geriatric population,^15–17 none have attempted a quantitative meta-analysis comparing IMFN to ORIF, likely due to the scarcity of high-quality studies conducted solely in the elderly. Prior meta-analyses have compared these two fixation techniques,^18–23 but the inclusion of younger adults has limited conclusions regarding the utility and safety of IMFN fixation in elderly patients, specifically. In this systematic review and meta-analysis, we aim to report complication and re-intervention rates in geriatric ankle fractures treated with IMFN and compare these outcomes to the current standard of care, ORIF.

2 Methods

2.1

2.1 Search strategy

A literature search was conducted on September 18, 2025 in MEDLINE (PubMed), EMBASE, Academic Search Premier, and Web of Science databases using the following keywords with their synonyms: (elderly) AND (distal fibula fracture) AND (intramedullary fixation) AND ((mortality) OR (quality of life) OR (nonunion) OR (wound infection) OR (complication)). Grey literature sources (ProQuest Dissertations & Theses, Google Scholar) and trial registries (ClinicalTrials.gov, Cochrane Library) were also queried, and reference lists of relevant review articles were manually screened for additional studies. A comprehensive list of search terms is provided in Appendix A.

Two authors (S.H., Q.N.) independently screened titles and abstracts using pre-defined inclusion and exclusion criteria, followed by full-text review of eligible articles. Discrepancies were resolved by discussion or a third reviewer (M.D.B.). A pilot test of 50 abstracts was performed to calibrate reviewer agreement, and inter-rater reliability was assessed using Cohen's kappa statistic. The search strategy was conducted with adherence to the PRISMA 2020 reporting checklist, with results outlined in Fig. 1.

PRISMA (preferred reporting items for systematic reviews and meta-analyses) flow diagram of search results and screening.

2.2

2.2 Eligibility criteria

Eligible studies were original research articles, conducted in a study population with a mean age ≥65 years, and reported postoperative outcomes in patients undergoing IMFN for unstable distal fibula fractures. Studies were excluded if they selectively included patients with polytrauma, periprosthetic fractures, pathologic fractures, or stress fractures. Quality improvement studies, case studies, review articles, and preclinical studies were excluded, as were studies without full-text, English-language articles accessible for review.

2.3

2.3 Data extraction and statistical analysis

Two reviewers (M.D.B., V.A.) independently extracted data from eligible studies and assessed study quality and bias. Statistical analysis was performed in RevMan 5.4 per Cochrane guidelines. Outcomes were reported as risk ratios (RR) with 95 % confidence interval (CI), and statistical significance was defined as p < 0.05. Between-study heterogeneity was assessed using Cochran's Q and the I² statistic, interpreted as low (0–40 %), moderate (30–60 %), substantial (50–90 %), or considerable (75–100 %). A fixed-effects model was applied for low to moderate heterogeneity (P > 0.10 and I² ≤ 50 %), while a random-effects model (DerSimonian–Laird method) was used for substantial/considerable heterogeneity (P < 0.10 and I² > 50 %).

3 Results

3.1

3.1 Study and patient characteristics

Thirteen studies were included in the review (Table 1).^24–36 Inter-rater reliability indicated moderate agreement in study selection (κ = 0.46). In total, 421 patients underwent IMFN fixation (67.5 % female), with mean study age ranging from 66 to 82.5 years. Although Peeperkorn et al. and Odeh et al. reported median ages, both studies were included because they exclusively studied older adults with minimum ages of 67 and 60 years, respectively. All fractures were classified as AO/OTA type 44-B (Weber B) or 44-C (Weber C). Most studies used the Accumed fibular nail, except Ramasamy et al. and Rajeev et al., who used the Biomet SST fibular nail.

Table 1 Characteristics of included studies.

Author (year)	Country	Study Type	N	Sex (M:F)	Mean Age (years)	Mean Follow-up (months)
White (2016)	U.K.	RCT	50	14:36	74	12
Stake (2023)	Norway	RCT	51	19:32	69	24
Lin (2024)	China	RCS	32	14:18	71.7	52
Tas (2022)	Netherlands	RCS	13	1:12	82.5	6
Peeperkorn (2018)	Belgium	RCS	15	5:10	75^a	19^a
Ramasamy (2001)	U.K.	CS	9	2:7	67.2	25.9
Karkkola (2020)	Finland	CS	41	22:19	68	43.9
Challagundla (2018)	U.K.	CS	15	3:12	74	12
Ashman (2016)	Canada/U.K.	CS	24	6:18	67	12^a
Rajeev (2011)	U.K.	CS	24	2:22	79	7
Odeh (2024)	U.K.	CS	15	1:14	76^a	5
Ahmed (2022)	U.K.	CS	95	40:55	66	NR
Appleton (2006)	U.K.	CS	37	8:29	67	14.5
			Total: 421	Total: 137:284

a Study reported median age or follow-up.

3.2

3.2 Postoperative complications of IMFN

Commonly reported postoperative complications included infection, malunion or nonunion, revision, symptomatic hardware, and hardware removal (Table 2). All thirteen studies monitored for infection, with an overall rate of 3.56 % in a total of 421 nails. Five studies observed no postoperative infections (0 %), while the highest infection rate was reported by Tas et al. (15.4 %). Ten studies reported malunion/nonunion and revision: 13/356 fractures (3.56 %) developed malunion/nonunion (range: 0–8.4 %), with time to union (8.7–16 weeks) reported in three studies,²⁶^,³³^,³⁵ and 16/352 nails (4.55 %) required revision (range: 0–11.1 %). Six studies assessed patients for prominent or painful hardware and found that 12/168 patients (7.14 %) experienced these symptoms (range: 0–13.3 %). Eight studies reported hardware removal in 25/295 patients (8.47 %; range: 2.1–13.7 %). Most hardware removals were partial, with the removal of one or more locking screws without removal of the nail.

Table 2 Complications of fibular nailing in geriatric ankle fractures.

Author (year)	N	Total Wound Infections	Malunion or Nonunion	Revisions	Symptomatic Hardware	Hardware Removals
White (2016)	50	0	1	0	0	5
Stake (2023)	51	2	4	5	6	7
Lin (2024)	32	1	0	–	–	3
Tas (2022)	13	2	–	–	0	1
Peeperkorn (2018)	15	1	0	1	1	2
Ramasamy (2001)	9	0	0	1	–	–
Karkkola (2020)	41	1	0	4	–	–
Challagundla (2018)	15	0	0	0	2	2
Ashman (2016)	24	2	0	1	3	3
Rajeev (2011)	24	0	0	–	–	–
Odeh (2024)	15	0	–	0	–	–
Ahmed (2022)	95	4	8	2	–	2
Appleton (2006)	37	2	–	2	–	–
	Total: 421	Weighted Average: 3.56 %	Weighted Average: 3.65 %	Weighted Average: 4.55 %	Weighted Average: 7.14 %	Weighted Average: 8.47 %

Mortality reporting varied significantly across studies. All studies reported deaths that occurred during follow-up except Ahmed et al., which excluded deceased patients. Three studies reported ≤6 month mortality: Appleton et al. (8.1 %), Odeh et al. (13.3 %), and Tas et al. (0 %). Five studies reported one-year mortality, ranging from 0 % (White et al., Rajeev et al.) to 13.3 % (Challagundla et al.), and three studies reported two-year mortality, ranging from 3.9 % (Stake et al.) to 19.5 % (Karkkola et al.). Ashman et al. reported the only three-year mortality rate (25 %).

3.3

3.3 Quantitative meta-analysis of comparative studies

Five of the included studies compared outcomes of IMFN to ORIF and were subject to a quantitative meta-analysis.^24–28 All studies included in the meta-analysis had a minimum age of 60 years and a mean age >65 years.

3.3.1

3.3.1 Risk of bias assessment

The Risk of Bias In Studies of Interventions (ROBINS) tool was used to assess the methodological quality of each study across several domains. The overall risk of bias for all five studies was low or moderate (Fig. 2). Three studies were retrospective in design with concern for potential confounding or unblinded outcome assessments but did not reach a level of serious limitations. Tas et al. received a serious risk of bias for confounding because the IMFN group had a significantly higher age and comorbidity burden compared to the ORIF group, although the overall risk of bias was moderate. A sensitivity analysis was performed for each outcome of interest to determine if any single study had significant bias over the results. Funnel plots showed no significant influence for any one study (Appendix B), and all studies were deemed adequate for inclusion.

Risk of Bias Summary. The Risk of Bias In Studies of Interventions (ROBINS) tool was used to assess studies for potential biases across several domains.

3.3.2

3.3.2 Wound Complications

Our analysis of wound complications included all five comparative studies consisting of 161 patients in the IMFN group and 374 patients in ORIF group. All studies reported fewer infections in patients treated with IMFN except for Tas et al., which reported a slightly lower infection rate in the ORIF group (15.4 % vs. 13.3 %). Heterogeneity was low (p = 0.27; I² = 23 %), prompting the use of a fixed-effects model. The pooled risk of infection was significantly lower in the IMFN group compared to the ORIF group (RR = 0.34; CI: [0.15, 0.74]; p = 0.007), suggesting patients who received IMFN demonstrated a 66 % decreased risk of wound complications (Fig. 3). A subgroup analysis revealed that the IMFN group demonstrated a significantly lower rate of superficial wound complications (RR = 0.37; p = 0.02) versus ORIF but did not differ with regards to deep wound complications (RR = 0.46; p = 0.34).

Forest Plot of Wound Complications for Patients who received Intramedullary Fibular Nailing Versus Open Reduction Internal Fixation M-H: Mantel-Haenszel; CI: confidence interval.

3.3.3

3.3.3 Hardware complications

All five studies reported hardware removals, and three studies reported symptomatic hardware. Hardware complications were generally less common in fractures fixed with IMFN, and Stake et al. was the only study to report a higher incidence of both outcomes in IMFN versus ORIF. However, our pooled analysis demonstrated that there was not a significant difference in the risk of hardware removal (RR = 0.74; p = 0.27) (Fig. 4) or symptomatic hardware (RR = 0.59; p = 0.24) (Fig. 5) between groups. Heterogeneity was low for hardware removals (p = 0.69; I² = 0 %) and moderate for symptomatic hardware (p = 0.13; I² = 50 %).

Forest Plot of Hardware Removals for Patients who received Intramedullary Fibular Nailing Versus Open Reduction Internal Fixation M-H: Mantel-Haenszel; CI: confidence interval.

Forest Plot of Symptomatic Hardware for Patients who received Intramedullary Fibular Nailing Versus Open Reduction Internal Fixation M-H: Mantel-Haenszel; CI: confidence interval.

3.3.4

3.3.4 Overall complications

Other complications of interest included malunion/nonunion, revision, and deep vein thrombosis (DVT). The overall incidence of malunion/nonunion and revision were lower in the ORIF group, while fractures fixed via IMFN were less likely to be complicated by DVT. Our pooled analysis showed that the risk of malunion or nonunion (RR = 1.20; p = 0.74) (Fig. 6), revision (RR = 1.45; p = 0.49) (Fig. 7), and DVT (RR = 0.72; p = 0.69) (Fig. 8) did not differ significantly between groups. Heterogeneity for all three outcomes was low.

Forest Plot of Malunion or Nonunion for Patients who received Intramedullary Fibular Nailing Versus Open Reduction Internal Fixation M-H: Mantel-Haenszel; CI: confidence interval.

Forest Plot of Revisions for Patients who received Intramedullary Fibular Nailing Versus Open Reduction Internal Fixation M-H: Mantel-Haenszel; CI: confidence interval.

Forest Plot of Deep Vein Thromboses in Patients who received Intramedullary Fibular Nailing Versus Open Reduction Internal Fixation M-H: Mantel-Haenszel; CI: confidence interval.

4 Discussion

The purpose of this systematic review and meta-analysis was to evaluate postoperative outcomes in unstable geriatric ankle fractures fixed with IMFN and compare them to the gold standard fixation technique, ORIF. An analysis of thirteen studies demonstrated that infection, nonunion/malunion, and revision occurred in <5 % of fractures fixed with IMFN, and <10 % of patients experienced symptomatic hardware or required hardware removal postoperatively. In addition, a quantitative meta-analysis of five comparative studies demonstrated that both techniques had comparable rates of revision, malunion/nonunion, symptomatic hardware, hardware removal, and DVT in adults >60 years of age. However, fractures fixed with IMFN were significantly less likely to become infected versus ORIF.

The minimally invasive nature of IMFN fixation allows for relatively shorter operative times, earlier return to weightbearing activity, and minimal damage to the periosteum and fracture hematoma.^37–39 These factors likely contribute to a significantly decreased risk of superficial wound infection and may also slightly lower the risk of DVT postoperatively. Our findings are consistent with prior meta-analyses conducted in adults ≥18 years, which reported significantly reduced wound complication rates in fractures fixed with IMFN versus ORIF.¹⁸^,²³ A decreased risk of infection may be of particular benefit to older adults with poor circulation, immune function, or wound healing at baseline.

Discomfort from prominent hardware is a commonly reported complication in elderly patients who have undergone ORIF.⁴⁰^,⁴¹ One study found that 60 % of adults over the age of 65 reported persistent pain, swelling, and/or difficulty with activities of daily living at 12 months post-op.⁴² Although our analysis demonstrated lower rates of symptomatic hardware and hardware removal in IMFN versus ORIF, the difference was not statistically significant. A previous meta-analysis conducted by Tas et al. in the general population observed a significantly lower rate of implant removals in IMFN versus ORIF (OR = 0.11; p < 0.01),²³ corroborating the potential risk of prominent hardware post-ORIF.

However, ORIF may be more stable than IMFN. A meta-analysis conducted by Zhang et al. reported significantly lower rates of hardware failure in adults ≥18 years treated with ORIF versus IMFN (RR = 2.05), with an overall hardware failure rate of 13.1 % in the IMFN group.¹⁹ A subgroup analysis in elderly patients was conducted using results from White et al. and Stake et al., and revealed that IMFN was over 4 times more likely to be complicated by hardware failure than ORIF in older adults.¹⁹ Tas et al. observed a significantly lower rate of nonunion (OR = 0.31; p < 0.01), but not malunion (OR = 0.45; p = 0.11), after IMFN versus ORIF,²³ while Migliorini et al., Cook et al., and Samuel et al. observed no difference in the union rate between groups.^20–22 In this study, we observed a slightly lower incidence of malunion/nonunion and revision in fractures fixed with ORIF, though the difference was not statistically significant.

We were unable to compare postoperative mortality or functional outcomes in our quantitative meta-analysis due to high variability in data reporting and follow-up time between studies. However, these are two crucial measures of postoperative success and quality of life. The Olerud Molander Ankle Score (OMAS) and the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot questionnaire were commonly reported measures of postoperative functional outcomes. White et al., Stake et al., and Lin et al. observed similar OMAS in elderly patients treated with IMFN versus ORIF with follow-up times ranging from 1 to 2 years. Stake et al. observed significantly higher AOFAS scores in fractures fixed with ORIF versus IMFN at 6-months after surgery, but the difference was not sustained at 12 months and 2 years. Peeperkorn observed significantly higher AOFAS scores in the IMFN group, though follow-up time was highly variable and the questionnaire response rate for the ORIF group was poor (41 %). A significant difference in long-term functional outcomes between IMFN and ORIF has not been observed in previous meta-analyses.^18–23

4.1

4.1 Limitations

This study is primarily limited by the paucity of high-quality randomized controlled trials evaluating IMFN in elderly patients. Only five comparative studies were identified, of which only two were prospective in design. While this limits our sample size and the statistical power of our analysis and conclusions, it highlights the importance of conducting additional studies on the use of IMFN in older adults, specifically. Because some studies excluded patients who died during follow-up and only published studies were included in our analysis, this study is susceptible to both survivorship and publication bias.

The lack of standardized outcome reporting between studies may undermine the validity of pooled results. There was occasional discordance in outcomes between studies, and additional high-level studies are needed to determine if a true difference in these outcomes exists. For example, the two randomized controlled trials (White et al., Stake et al.) reported discordant findings on outcomes such as hardware removal, symptomatic hardware, and revisions in their respective comparisons of IMFN versus ORIF. Finally, variation in follow-up time, antibiotic prophylaxis, and patient characteristics such as fracture classification, age, and comorbidity burden may also affect the results.

4.2

4.2 Conclusions

This systematic review and meta-analysis demonstrates that IMFN is associated with a significantly lower risk of superficial wound infections compared to ORIF in geriatric ankle fractures. When compared to IMFN, fractures fixed with ORIF may be less likely to require reoperation for symptomatic hardware but more likely to require revision for malunion/nonunion, although no significant difference in the incidence of these complications was observed between techniques. Our findings are largely in alignment with previous meta-analyses conducted in the general population, indicating that IMFN is a viable alternative to ORIF in all age groups. However, small sample sizes and risk of bias limit these conclusions, and additional high-quality studies with a focus on geriatric care are needed. Ultimately, the decision regarding fixation technique should be made cautiously with a thorough and individualized evaluation of each patient's preoperative condition, including factors such as fracture characteristics, bone density, comorbidities, and baseline activity level.

Compliance with ethical standards

No disclosures nor conflicts of interest. No informed consents or IRB approval needed, due to study design.

Author roles and contributions

Conceptualization: MDB, VA, SH, QC, LKC.

Data curation: MDB, VA, SH, QC.

Formal analysis: MDB, VA.

Funding acquisition: N/A.

Investigation: MDB, VA, SH, QC.

Methodology: MDB, VA, SH, QC, LKC.

Project administration: LKC.

Resources: LKC.

Software: VA.

Supervision: LKC.

Validation: LKC.

Visualization: MDB, VA, SH, QC.

Roles/Writing - original draft: MDB.

Writing - review & editing: MDB, VA, SH, QC, LKC.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Rushing C.J., . Comparison of ankle fracture fixation using intramedullary fibular nailing versus plate fixation. J Foot Ankle Surg. Sep-Oct 2024;63(5):546-556.
[Google Scholar]
Baumbach S.F., Rellensmann K., Spindler F.T., et al . Immediate weight bearing without immobilization for operatively treated ankle fractures is safe - a systematic review. Foot Ankle Surg. Jun 2023;29(4):306-316.
[Google Scholar]
Walton D.M., Adams S.B., Parekh S.G., . Intramedullary fixation for fractures of the distal fibula. Foot Ankle Int. Jan 2016;37(1):115-123.
[Google Scholar]
Brown O.L., Dirschl D.R., Obremskey W.T., . Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma. May 2001;15(4):271-274.
[Google Scholar]
Schepers T., Van Lieshout E.M., De Vries M.R., et al . Increased rates of wound complications with locking plates in distal fibular fractures. Injury. Oct 2011;42(10):1125-1129.
[Google Scholar]
Nilsson G., Jonsson K., Ekdahl C., et al . Outcome and quality of life after surgically treated ankle fractures in patients 65 years or older. BMC Muscoskelet Disord. Dec 20 2007;8:127.
[Google Scholar]

Introduction

Methods

Search strategy
Eligibility criteria
Data extraction and statistical analysis

Results

Study and patient characteristics
Postoperative complications of IMFN
Quantitative meta-analysis of comparative studies

Discussion

Limitations
Conclusions

Patient consent

Compliance with ethical standards

Author roles and contributions

Funding

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[Google Scholar]

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[Google Scholar]

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[Google Scholar]

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[Google Scholar]

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[Google Scholar]

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[Google Scholar]

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[Google Scholar]

Intramedullary fibular nailing versus open reduction internal fixation for unstable geriatric ankle fractures: A systematic review and meta-analysis

Abstract