The Fracture Ankle Implant Review (FAIR) Study: A national multicentre retrospective review of implants, fixation methods and outcomes in fibula fixation in ankle fractures

W. Fishley, R. Morrison, T. Baldock, A. Hilley, FAIR Collaborative, CORNET, P. Baker, D. Townshend

Background: In fixation of the fibula in ankle fractures, AO advocate using a lag screw and one-third tubular neutralisation plate for simple patterns. Where a lag screw cannot be placed, bridging fixation is required. A local pilot service evaluation previously identified variance in use of locking plates in all patterns with significant cost implications. The FAIR study aimed to evaluate current practice and implant use across the United Kingdom (UK) and review outcomes and complication rates between different fibula fixation methods.

Methods: The study was supported by CORNET, the North East trainee research collaborative, and BOTA. Data was collected using REDCap from 22 centres in the UK retrospectively for a one-year period between 1st January 2019 and 31st December 2019 on injury mechanism, fracture characteristics, comorbidities, fixation and complications. Followup data was collected to at least two-years from the time surgery.

Results: 1479 ankle fractures which involved fixation of the fibula were recorded; one-third tubular plate was used in 883 (59.7%) cases, a locking plate in 470 (31.8%) cases and other methods in 118 (8.1%) cases. There was significant difference between centres (p<0.001) in implant type used. Other factors associated with implant type were age, diabetes, osteoporosis, open fractures and the presence of comminution. Incidence of lateral wound breakdown and infection was higher in locking plates than one-third tubular plates (p<0.05) in AO44B fractures. There was no significant difference in non-union, fixation failure or removal of metalware.

Conclusion: There is significant variation in practice in the UK in implant use for fixation of the fibula in ankle fractures. Potentially unnecessary use of locking plates, where a one-third tubular shows equivalent outcomes, incurs additional cost and may increase the risk of lateral wound complications. We would encourage surgeons with high locking plate usage to evaluate their own unit’s practice against this data.