Assessing Articular Cartilage and CFL Damage Following Fibular Nailing: A Cadaveric Study

Submission Type: Ankle Fractures Research Type: Level 5 - Case report, Expert opinion, Personal observation Introduction/Purpose: Traditional surgical fixation of ankle fractures involves the application of plates and screws, which carries a risk of wound complications, hardware prominence, and soft tissue irritation. Intramedullary (IM) fibular nailing offers a minimally invasive alternative with potentially lower complication rates. Evidence is lacking regarding the impact of fibular nailing on structures around the insertion site of the nail, particularly the articular cartilage of the distal fibula and the calcaneofibular ligament (CFL), where damage could lead to degenerative changes, instability, or pain. Methods: In order to address this gap, this study assessed the risk and extent of damage to surrounding anatomical structures during IM nail fixation on 10 clinical-grade cadaver lower extremities. Risk was classified based on distances from the nail to the CFL, anterior talofibular ligament (ATFL), sural nerve (SN), superficial peroneal nerve (SPN), peroneus longus (PL), peroneus brevis (PB), and articular cartilage: high-risk (0–5 mm), moderate-risk (5.1–10 mm), or low-risk (over 10 mm). Distance measurements and damage quantification was completed by two observers. Results: The CFL was damaged in 3 out of 10 specimens, ranging from 14% to 64% of the ligament's width. The average distances to the CFL (1.20 mm), ATFL (3.43 mm), PB (3.19 mm), and articular cartilage (3.45 mm) were within the high-risk range, though no significant damage was observed to the articular cartilage, ATFL, SN, or SPN. Conclusion: This study further confirms that IM fibular nailing is a generally safe and a reliable option for treating ankle fractures, though careful attention should be given to the potential for iatrogenic damage to high-risk soft-tissue structures, particularly the CFL and peroneal tendons.