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Abstract
Purpose
The purpose of this study was to evaluate the radiologic outcomes of distal fibular fractures and to analyze the risk factors associated with nonunion.
Materials and Methods
Between January 2009 and March 2016, 13 patients who had final nonunion with ankle fracture were included. In the control group, 370 patients who had undergone bony union and removed metal implants were included. All patients underwent the same surgical procedure and had the same treatment method, ultimately achieving satisfactory open reduction results with less than 2 mm fracture gap. Surgical treatment of fracture was considered to have the same effect on nonunion, and factors that might be associated with nonunion were evaluated. SPSS ver. 13.0 (SPSS Inc., USA) was used for all statistical analyses. Pearson's chi-square test and multi-variate regression analysis were performed to determine the factors affecting nonunion of distal fibular fracture. A p-value less than 0.05 was considered statistically significant, and relative risk was assessed.
Results
The mean age of 13 patients was 46.9 years (range, 16∼57 years); there were 8 men and 5 women. Among the 13 patients with nonunion, atrophic was the most common (12 cases). The association between the injury mechanism and the Lauge-Hansen classification and diabetes mellitus was not statistically significant. Distal fibular fractures with tibia shaft fracture (p=0.015) and Danis-Weber type C fracture (p=0.023), open fracture (p=0.011), and smoking (p=0.023) were significantly associated with nonunion.
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References
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 | Figure 1.A 68-year-old male with lateral malleolar fracture (Denis-Weber type B, Lauge-Hansen supiration-external rotation type) visited our clinic after conservative treatment. (A, B) Ankle anteroposterior and lateral view taken 6 months after the injury showed lateral malleolar nonunion. (C, D) Ankle computed tomography showed sclerotic lesion of the fracture site and fracture gap. (E, F) He underwent plate and screw fixation of the fibula with autogenous iliac crest bone graft. Radiographs taken 9 months postoperatively demonstrate complete healing. He had diabetes, smoking of nonunion risk factors. |
 | Figure 2.A 40-year-old male presents for evaluation of continued ankle pain 8 months after open reduction and internal fixation of a bimalleolar fracture. (A) Initial ankle anteroposterior view at injury shows left ankle bimalleolar fracture (Denis-Weber C, Lauge-Hansen pronation-external rotation type) with syndesmosis injury. (B) Internal fixation was performed using a cannulated screw and 1/3 semitubular plate. (C, D) Radiograph and computed tomography demonstrate an atrophic nonunion. (E) The patient underwent operative revision with iliac crest bone graft. |
Table 1.
Associated Factors to Fibular Nonunion after Treatment of Lateral Malleolar Fractures
| Nonunion (n=13) | Union (n=370) | p-value∗ | p-value† | ||
|---|---|---|---|---|---|
| Injury mechanism | Motor vehicle accident | 7 (53.8) | 89 (24.1) | 0.086 | 0.094 |
| Slip down | 3 (23.1) | 173 (46.8) | 0.165 | 0.271 | |
| Fall down | 2 (15.4) | 62 (16.8) | 0.594 | 0.341 | |
| Direct injury | 1 (7.7) | 46 (12.4) | 0.432 | 0.706 | |
| Combined injury | Tibia shaft fracture | 8 (61.5) | 64 (17.3) | 0.015‡ | 0.009 |
| Malleolar fracture | 2 (15.4) | 125 (33.8) | 0.067 | 0.301 | |
| Syndesmosis injury | 2 (15.4) | 104 (28.1) | 0.627 | 0.493 | |
| Deltoid ligament rupture | 2 (15.4) | 8 (2.2) | 0.071 | 0.107 | |
| Denis-Weber type | Type A | 0 (0) | 18 (4.9) | 0.196 | 0.189 |
| Type B | 3 (23.1) | 198 (53.5) | 0.432 | 0.382 | |
| Type C | 10 (76.9) | 154 (41.6) | 0.023§ | 0.009 | |
| Lauge-Hansen type | Supiration-aduction | 0 (0) | 15 (4.1) | 0.206 | 0.267 |
| Supiration-external rotation | 3 (23.1) | 98 (26.5) | 0.108 | 0.362 | |
| Pronation-external rotation | 1 (7.7) | 85 (23.0) | 0.271 | 0.176 | |
| Pronation-adduction | 1 (7.7) | 18 (4.9) | 0.317 | 0.471 | |
| Fracture | Open fracture | 8 (61.5) | 17 (4.6) | 0.011∥ | 0.000 |
| Comminuted fracture | 5 (38.5) | 58 (15.7) | 0.073 | 0.142 | |
| Patient factor | Diabetes mellitus | 1 (7.7) | 24 (6.5) | 0.624 | 0.639 |
| Smoking | 7 (53.8) | 54 (14.6) | 0.023¶ | 0.002 |
Denis-Weber type: Type A are caused by internal rotation and adduction that produce a transverse fracture of the lateral malleolus at or below the plafond. Type B are caused by external rotation resulting in an oblique fracture of the lateral malleolus, beginning on the anteromedial surface and extending proximally to the posterolateral aspect. Type C are divided into abduction injuries with oblique fracture of the fibula proximal to the disrupted tibiofibular ligaments (C-1) and abduction-external rotation injuries with a more proximal fracture of the fibula and more extensive disruption of the interosseous membrane (C-2).
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