Minimally Invasive Intramedullary Nailing for Distal Fibular Fractures: Is it Safe and Efficient? A Cadaveric Study

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: The use of intramedullary fibular nailing for ankle fracture fixation has gained popularity, particularly in patients at elevated risk of wound complications. Despite its advantages, concerns remain regarding the safety of this technique and the quality of fracture reduction achieved through its minimally invasive approach. This anatomical study aimed to evaluate the potential risks to adjacent anatomical structures during the implantation of a percutaneous retrograde locked intramedullary fibular nail and to analyze the quality of fracture reduction using radiographic assessment. Methods: Ten human cadaveric lower extremities were subjected to a simulated fracture and then fixed with a nail. Reduction quality was evaluated fluoroscopically and graded accordingly. Specimens were dissected to assess damage to nearby anatomical structures, and the shortest distances between surgical sites and adjacent structures were measured. Results: Reduction quality was deemed adequate in all specimens. No damage to the peroneal tendons was observed. The mean distance between the sural nerve and the distal portal was 14.95 mm (SD 3.99) therefore this was considered a safe zone. The superficial peroneal nerve (SPN) was identified as the structure at the highest risk of injury, with a mean distance of 4.52 mm (SD 3.27) from the anterior portal and 14.17 mm (SD 5.25) from the lateral portal. The SPN was found in contact with the anterior portal in three specimens, however no structures were injured during instrumentation. Conclusion: Adequate fracture reduction can be achieved with the nail. The SPN was identified as the structure at the highest risk of damage; however, no tendons or nerves were injured during the procedure. Clinical relevance: The current findings supports intramedullary nailing as an efficient method for achieving proper fracture reduction while minimizing soft tissue complications. Nevertheless, strict adherence to the percutaneous technique is essential to minimize iatrogenic injury to neighboring structures. This includes using skin-only incisions, performing blunt dissection down to the bone, and maintaing close approximation of protection sleeves and bone at all times.