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FAIXXX10.1177/1071100717709572Foot & Ankle InternationalGoss et al

Article
Foot & Ankle International

Anatomic Structures at Risk When

15
The Author(s) 2017
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DOI: 10.1177/1071100717709572
https://doi.org/10.1177/1071100717709572

Fibular Fractures: A Cadaveric Study journals.sagepub.com/home/fai

David A. Goss Jr, DO1, Christopher W. Reb, DO2, and Terrence M. Philbin, DO3

Abstract
Background: Retrograde intramedullary fibular nail fixation is being utilized with increasing frequency, particularly in
patients at higher risk of wound complications. The purpose of this anatomic study was to assess the relative risk to nearby
anatomic structures when implanting a contemporary retrograde locked intramedullary fibular nail.
Methods: Ten human cadaveric lower extremities were instrumented with a fibular nail. The cadavers were dissected.
The shortest distance, in millimeters (mm), between the site of procedural steps and nearby named structures of interest
(ie, sural nerve, superficial peroneal nerve, and the peroneal tendons) was measured and recorded. Levels of risk were
assigned based on observed distances as high (0 to 5 mm), moderate (5.1-10 mm), and low (greater than 10 mm).
Results: The peroneus brevis (PB) tendon was found to be less than 5.0 mm from the distal skin incision in all specimens.
When reaming and inserting the nail through the distal fibula aperture, the PB was less than 5.0 mm in 6 specimens. The
peroneus longus tendon was at moderate to high risk when inserting both the proximal and distal syndesmotic screws in
9 specimens. The superficial peroneal nerve was at high risk when inserting an anterior to posterior distal locking screw in
7 specimens. The sural nerve was at low risk for all procedural steps. No structures were violated or damaged during any
portion of the fibular nail instrumentation.
Conclusion: The peroneal tendons and superficial peroneal nerve were at the highest risk; however, no structures were
injured during instrumentation.
Clinical relevance: The current findings indicate that strict adherence to sound percutaneous technique is needed in
order to minimize iatrogenic damage to neighboring structures when performing retrograde locked intramedullary fibular
nail insertion. This includes making skin-only incisions, blunt dissection down to bone, and maintaining close approximation
between tissue protection sleeves and bone at all times.

Keywords: fibula, fracture, surgery, ankle, intramedullary nail

Introduction study comparing distal fibular plating with nailing, the

Ankle fractures are commonly encountered by orthopedic
surgeons and make up approximately 9% of all fractures.4
Also, there is a continually increasing number of diabetic,
osteoporotic, and elderly patients presenting with these inju-
ries.8,15 Traditionally, these fractures have been addressed
with lateral plate and screw fixation. However, in an effort to
minimize the complications associated with this type of fixa-
tion, the development and use of alternative fixation, such as
posterolateral plating, locked distal fibular plating and intra-
medullary (IM) devices, has increased. A 30% complication
rate is commonly reported with fibular plating constructs,
which largely consists of hardware irritation, wound break-
down, and infection.7 Recent studies have reported compli-
cation rates of 7 and 10.3% when utilizing IM fibular
nailing.2,7 In a recently published prospective, randomized
authors found no difference in union rates between the 2
groups; however, there was a significant difference in the
complication rates favoring nailing (7% vs 56%).2
Despite a decreased complication rate with IM fibular
nailing, there are several nearby structures that are suscep-
tible to injury during the procedure. Several studies have
1
OhioHealth Doctors Hospital, Columbus, OH, USA
2
Department of Orthopaedics and Rehabilitation, Division of Foot and
Ankle Surgery, University of Florida College of Medicine, Gainseville, FL,
USA
3
Orthopedic Foot and Ankle Center, Westerville, OH, USA
Corresponding Author:
Terrence M. Philbin, DO, Orthopedic Foot and Ankle Center,
300 Polaris Parkway, Suite 2000, Westerville, OH 43082, USA.
Email: ofacresearch@orthofootankle.com
2 Foot & Ankle International 0(0)

evaluated the relative risk of damage to nearby structures

when performing open reduction and internal fixation of
distal fibula fractures with lateral plate and screw fixa-
tion;5,14 however, no such studies have evaluated the struc-
tures at risk with IM fibular nailing. As a result, the purpose
of this study was to conduct an anatomic analysis with
cadaveric specimens in order to determine the structures at
risk when performing IM fibular nailing utilizing a modern
generation nail design.

Materials and Methods

This was an IRB exempt study due its cadaveric nature. All
specimens were examined for previous incisions, scars, and
evidence of pathologic tissue. No specimens demonstrated
abnormal pathology, evidence of previous surgery or
trauma. Ten fresh-frozen cadaver lower extremities were
instrumented with a contemporary retrograde locked IM
fibular nail (FibuLock Ankle Pin, Sonoma Orthopedic
Products, Inc, Buffalo Grove, IL), which provided 3 distal
locking and 2 syndesmotic fixation screw options (Figure
1). A standardized insertion technique with the incorpora- Figure 1. Anteroposterior ankle radiograph with instrumented
fibular nail.
tion of a portable c-arm was utilized for nail placement.
After nail insertion, all specimens were dissected by a sin-
gle experienced orthopedic foot and ankle surgeon (T.M.P.)
in a standardized fashion. The specimens consisted of 5
males and 5 females, with an average age of 76.8 years at
time of death. Five of the specimens were right sided and
the remaining 5 were left.
The shortest distance, in millimeters, between the site of
procedural steps and nearby named structures of interest (ie,
sural nerve, superficial peroneal nerve, and the peroneal
tendons) was measured with a digital caliper and recorded.
Levels of risk were then assigned based on observed dis-
tances as high (0-5 mm), moderate (5.1-10 mm), and low
(greater than 10 mm).

Results
The sural nerve, superficial peroneal nerve, and peroneal
tendons were identified in all specimens (Figure 2). The
peroneus brevis (PB) tendon was found to be less than 5.0
mm from the distal skin incision in all specimens (Table 1).
On average, the PB tendon was found to be 2.0 1.5 (range Figure 2. Illustration depicting structures in relation to incision
0.4-4.5) mm from the distal skin incision. The distal extent and screw placement: (A) peroneus brevis, (B) peroneus longus,
(C) sural nerve, (D) superficial peroneal nerve. Oval: incision
of the skin incision was a mean distance of 15.6 6.5 (range
for anteroposterior locking screw; circles: proximal and distal
7.4-27.1) mm from the sural nerve, and 19.0 7.5 (range syndesmotic screws; dark line: incision for fibular nail reaming.
1.1-27.6) mm from the superficial peroneal nerve. When
reaming and inserting the nail through the distal fibula aper-
ture, the PB was less than 5.0 mm in 6 specimens and less The peroneus longus (PL) tendon was at moderate to high
than 10 mm in the remaining 4. On average, the PB tendon risk (less than 10 mm) when inserting both the proximal and
was 2.6 2.5 (range 0.3-6.3) mm from the fibular aperture. distal syndesmotic screws in 9 specimens. The average dis-
The fibular aperture was found to be on average 21.4 7.1 tance of the PL from the proximal and distal syndesmotic
(range 7.4-31.4) mm from the superficial peroneal nerve. screws were 7.3 1.9 (range 3.9-10.9) mm and 7.4 1.6
Goss et al 3
Table 1. Number of Specimens With Structures at Risk.
High Risk,
0-5 mm
Distal skin incision to PBa
Distal skin incision to SPN
Distal skin incision to SN
Fibula aperture to PBa
Fibula aperture to SPN
Distal locking incision to PB
Proximal locking incision to PB
AP screw incision to SPNa
Proximal syndesmotic screw to PLa
Distal syndesmotic screw to PLa
Proximal syndesmotic screws to SN
Distal syndesmotic screw to SN
Abbreviations: AP, anteroposterior; PB, peroneus brevis; PL, peroneus longus; SN, sural nerve; SPN, superficial peroneal nerve.
a
Structures noted to be highest risk.
(range 5.1-10.6) mm, respectively. The distance between
both the proximal and distal locking screws averaged more
than 1 cm (11.0 and 12.4 mm, respectively) from the PB
tendon. With regard to the superficial peroneal nerve (SPN),
it was at highest risk when inserting an anterior to posterior
distal locking screw in 7 specimens. The anteroposterior
screw was on average 4.5 4.6 (range 0.3-12.9) mm from
the SPN. The sural nerve (SN) was at low risk for all proce-
dural steps. No structures were violated or injured during
any portion of the fibular nail instrumentation.
Discussion
Retrograde IM fixation of lateral malleolus fractures is not
a new concept. Over the last 25 years, multiple manuscripts
have detailed the use of minimally invasive techniques to
stabilize these fractures.1-3,9-11,13 Early attempts at intramed-
ullary fixation using Rush rods, Knowles Pins, Kirschner
wires, and nonlocked nails were fraught with implant com-
plications and loss of reduction.7 As a result, modern gen-
eration retrograde intramedullary fibular nails were
designed for proximal and distal locking to provide load-
sharing rigid intramedullary fixation, with only transaxial
locking screws residing below the skin surface.1,11 These
technological advances allow modern constructs to offer
fixation options, fitting a wide range of clinical scenarios,
such as oblique/spiral fractures, comminution, osteoporo-
sis, and concomitant syndesmotic injuries.
We used the FibuLock Ankle Pin (Sonoma Orthopedic
Products, Inc, Buffalo Grove, IL), which is a fibula-specific
stainless steel cannulated nail that can accommodate 3 dis-
tal multiplanar locking screws and 2 syndesmotic screws.
This nail obtains proximal fixation within the medullary
canal via triangulated talons that are deployed within the
diaphysis. However, regardless of the nailing system used,
Moderate Risk, Low Risk,
5.1-10 mm >10 mm
10 0 0
1 0 9
0 3 7
6 4 0
0 1 9
0 3 7
1 4 5
7 1 2
1 8 1
0 9 1
0 0 10
0 0 10
mindful planning and strict adherence to sound percutane-
ous technique from the start of the case is essential to pre-
vent inadvertent injury.
Iorio etal preformed a cadaveric study in which they eval-
uated the safest zone for a single retrograde percutaneous IM
wire placed within the distal fibula.6 They demonstrated the
least safe zone for percutaneous wire placement within the
distal lateral malleolus was posterolateral. This position
placed the sural nerve and peroneal tendons at risk. While
this study provides useful information regarding structures at
risk with a single wire placement, it did not address the com-
plexity of contemporary fibular nail fixation.
In our study, the peroneal tendons and SPN were at high-
est risk (less than 5 mm) during the procedure; however, no
structures were iatrogenically injured during the procedure.
We feel this was largely due to adherence of sound percuta-
neous techniques, including making skin-only incisions,
thorough blunt dissection down to bone, and maintaining
close approximation between tissue protection sleeves and
the bone at all times.
With regard to individual structures, the PB was at great-
est risk when making the initial skin incision and during
reaming and insertion of the nail through the fibular aper-
ture. Given the close proximity of the PB tendon, it is criti-
cally important to evaluate each patient preoperatively for
peroneal subluxation. In the event that subluxation is pres-
ent, these structures could pose an even greater risk to injury
during these procedural steps as well. Another structure in
close proximity to the peroneal tendons is the calcaneofibu-
lar ligament (CFL). Although not directly measured in this
study, it lies just deep to the peroneal tendons as they course
around the inferior aspect of the distal fibula. The intimate
relationship between these tendons and the CFL places this
structure at potential risk during these procedural steps as
well. The SPN was at greatest risk when inserting the
4 Foot & Ankle International 0(0)
anterior to posterior locking screw. Lastly, when placing the
syndesmotic screws, the peroneal longus tendon was at
moderate risk (less than 10 mm) for both the proximal and
distal screws because of the orientation of these screws. The
syndesmotic screws have a more posterior starting point in
order to facilitate the correct trajectory and as a result, more
closely approximate the PL tendon.
In reviewing the literature with respect to fibular nailing
outcomes, by and large, studies do not collect or record
postoperative data regarding nerve palsies or peroneal ten-
don pathology. Iatrogenic injury to the peroneal tendons or
SPN can certainly be a source of postoperative pain.
Attentive and mindful evaluation of patients with unex-
plained postoperative pain may yield injury to these struc-
tures. Ramasamy etal reported on 9 elderly patients with
Denis-Weber B ankle fractures that were treated with the
S.S.T. (Stainless Steel Taper) Small Bone Locking Nail
(Zimmer Biomet, Warsaw, Indiana).12 There was 1 case of
mechanical failure requiring ankle arthrodesis and no cases
of skin breakdown or nerve palsy in their small series. In a
retrospective review published in 2011, Rajeev etal reported
their results with the S.S.T. nail.11 Twenty-four patients with
fragility fracture were treated. There were no reported cases
of wound breakdown or deep skin infections, and no men-
tion of nerve or tendon pathology. Appleton etal published
their results of 37 elderly patients with unstable ankle frac-
tures that were treated with the Acumed Fibular Rod System
(Acumed LLC, Hillsboro, OR).1 They reported on 3 patients
who developed postoperative infections, 2 who lost reduc-
tion on the medial side of their injury, and 1 patient with
subluxation of the ankle posteriorly after nail fixation.
Again, no mention of tendon or nerve pathology was
reported. Another study involving the Acumed Fibular nail
was published by Bugler etal.3 In their manuscript, they
reviewed the results of 105 patients with unstable ankle
fractures treated with this device. Initially, heterogeneous
screw fixation techniques were used and reviewed; how-
ever, mechanical failure and complications were attributed
to these constructs. They reported that 7 patients developed
a loss of fracture fixation and 5 developed postoperative
wound infections. A uniform construct was later adopted,
which used both syndesmotic and distal locking screw fixa-
tion. Twenty-one patients who were treated with this con-
struct went on to achieve good fracture reduction, no
significant complications, and a single superficial skin
infection was reported in this group.
Despite the lack of documented complications involv-
ing the SPN and the peroneal tendons with fibular nailing
throughout the literature, our results indicate these may
be underreported and/or underappreciated entities, and
their consideration will hopefully be accounted for going
forward.
Several limitations existed with our study. There were
only 10 cadaveric specimens included in our study; as a
result, the amount of anatomic variation that occurs within
the general population was not able to be accounted for. The
specimens were fresh frozen and as a result did not truly
reflect tissue mobility and range of motion about the ankle
that would be normally encountered in the operating room.
The relatively fixed equinus posture of the specimens could
potentially affect the distances between structures at risk
and the instrumentation by not allowing flexion or exten-
sion. Lastly, given the cadaveric nature of this study, we
were unable to contribute to the literature regarding the
clinical indications and outcomes of this particular device.
In conclusion, the peroneal tendons and superficial
peroneal nerve were at greatest risk during this procedure;
however, none of these structures were violated or injured
during nail and screw placement, highlighting the impor-
tance of adhering to sound percutaneous surgical tech-
nique when utilizing this nailing system for distal fibular
fractures.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Terrence M. Philbin, DO has a patent at Sonoma with roy-
alties paid.
Funding
The author(s) declared receipt of the following financial support
for the research, authorship, and/or publication of this article:
DJO Global funded the cadaver lab.
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