Learning Curve and Early Outcomes of Intramedullary Fibula Nailing Using the FibuLock Nail: A Single-center Experience

Introduction: Ankle fractures are common, with about a quarter requiring surgical intervention. Plate-and-screw fixation remains the standard for fibula fractures, but intramedullary nails have gained attention for their minimally invasive approach and reduced hardware removal rates. The FibuLock nail offers biomechanical advantages and may lower soft-tissue complications, though adoption has been limited by mixed long-term outcome evidence. This study evaluates our early experience with the FibuLock system, focusing on complications, pitfalls, and the learning curve. Materials and methods: We retrospectively reviewed patients who underwent intramedullary fibula nailing from 2019 to 2024 at a single center. Demographics, fracture classification, and radiographic outcomes were collected. Complications included fixation failure, malpositioning of trans-syndesmotic fixation, and >2 mm fibular shortening. Reduction quality was graded using Kho's criteria. Three senior foot and ankle surgeons independently reviewed cases to determine the causes of complications. Results: Thirty procedures were analyzed; 70% of patients were female, and 42% were over 60 years old. Injuries were most often caused by falls (65%), followed by sports (19%), road traffic accidents (11%), and direct impact (4%). Comorbidities included peripheral vascular disease (11%), diabetes (23%), and end-stage renal failure (4%). Fractures were classified by AO criteria. Reduction quality ranged from good to excellent to fair and poor. Complications occurred in 19% of cases, including fibula shortening, tightrope malposition, and fixation failure requiring revision. Deep infection occurred in 6%, and early revision in 20%. Importantly, no complications or deep infections occurred after the first 19 cases. Conclusion: Intramedullary fibula nailing with the FibuLock system has a notable learning curve, with early technical complications decreasing as experience grew. Refinements in technique improved outcomes, offering guidance for surgeons adopting this method, especially in elderly patients, where soft tissue preservation is vital. Level of evidence: III