Intramedullary Fibular Nail Versus Plate Fixation for Adult Lateral Malleolus (Fibula) Fractures: A Systematic Review and Meta-Analysis

Ankle fractures are among the most common orthopaedic injuries. While plate fixation has long been the standard method for distal fibular stabilization, intramedullary nailing (IMN) has emerged as a minimally invasive alternative. The relative clinical effectiveness of these techniques remains uncertain. This systematic review and meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was registered with PROSPERO (ID: CRD420251143494). Randomized controlled trials (RCTs) and comparative cohort studies published between 2015 and 2025 were included. A comprehensive search of six databases identified nine eligible studies (five RCTs, four cohort studies). Data were pooled using fixed- or random-effects models, and heterogeneity was assessed with the I² statistic. Pooled analysis demonstrated no significant difference in long-term functional outcomes or time to union between IMN and plate fixation. IMN was associated with a significantly lower risk of wound complications (p = 0.008), reduced operative time (p = 0.025), fewer cases of symptomatic hardware (p = 0.004), and a lower rate of non-union (p = 0.022). Event rates, however, were low, and study heterogeneity was moderate. Both IMN and plate fixation achieve reliable fracture union and functional recovery. IMN offers perioperative advantages, particularly fewer wound complications and shorter operative times, making it an appealing option for elderly or high-risk patients. Nevertheless, the evidence base is limited by small sample sizes, moderate heterogeneity, and short follow-up durations. Larger, multicenter randomized trials are warranted to confirm these findings, clarify subgroup benefits, and determine long-term cost-effectiveness.