Plate Versus Intramedullary Nail Fixation for Distal Fibula Fractures: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Equipoise exists regarding implant choice for treating unstable distal fibula fractures. This study aimed to compare intramedullary nail (IMN) fixation and plate fixation (PF), considering solely randomised controlled trials (RCTs). A systematic review and meta-analysis of all published RCTs was conducted. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), and Cochrane databases were searched. Outcomes were patient-reported functional measures, union rates, complications, revision rates, and cost-effectiveness. The Cochrane risk-of-bias v2.0 tool was used for bias assessment. Five RCTs involving 455 patients (222 with IMN and 233 with PF) were included. Patient ages ranged from 18 to 93 years, with a mean age of 56.4 years. Functional outcomes, measured by the American Orthopaedic Foot and Ankle Society (AOFAS) score and Olerud and Molander Ankle Score (OMS), showed no significant differences between IMN and PF at 24 months. Meta-analysis demonstrated no significant difference in OMS at one year between studies (mean difference -2.33, 95% CI -10.03 to 5.37, P=0.55). Complication and union rates were similar between the groups. One study suggested cost savings with IMN despite the higher initial implant cost. Some concerns were raised about the risk of bias assessment of all the included studies. IMN and PF provide comparable functional recovery for distal fibula fractures with similar complication profiles. Patient-specific factors should guide the choice of fixation method. IMN may offer cost benefits for certain populations, though further research is needed. Larger longitudinal studies including outcomes such as return to work and sports are recommended to refine clinical guidelines for selecting the appropriate fixation method.