Elastic Locking Intramedullary Nails Fixation in Trimalleolar Fractures

Since the 1960s, although open reduction and internal fixation for ankle fractures has been widely used, it is associated with complications such as wound dehiscence, infection, prominent hardware, and failure. Closed reduction and internal fixation, on the other hand, offers greater biomechanical strength, requires minimal incisions, and features low-profile hardware. Our study compares the efficacy of elastic locking intramedullary nails (ELIN) fixation featuring minimally invasive microenvironmental protection microstress shielding versus rigid internal fixation (RIF) for trimalleolar fractures.

This retrospective study included a total of 39 patients (2020-2024), comprising 10 men and 29 women (mean age, 55.9 years), who were assigned to the ELIN group or the RIF group. Comparing the different variables between the two groups, including surgical incision length, intraoperative blood loss, operative time, time until union, time to device removal, AOFAS scores, ankle dorsiflexion, and plantar flexion, postoperative complications, and patient satisfaction. The surgical incision length, intraoperative blood loss, and operative time conformed to a normal distribution, so the independent t-tests were used for statistical analysis. Time until union, time to device removal, AOFAS scores, ankle dorsiflexion, and plantar flexion, and patient satisfaction did not conform to a normal distribution; thus, the Mann-Whitney U test was adopted.

All 39 patients were completed the surgery successfully. ELIN fixation is superior to RIF in surgical incision length (p < 0.001), intraoperative blood loss (p = 0.047), operative time (p < 0.001), time until union (p = 0.003), and time to device removal (p < 0.001), with significant differences in the above parameters between the two groups. The AOFAS scores (p = 0.553), ankle dorsiflexion (p = 0.904), and plantar flexion (p = 0.799) were not significantly different between the two groups. One case of ankle pain was reported in each group at the sixth month postoperatively. By the end of the follow-up, the pain in these two cases had lessened or even disappeared after the patients reduced weight bearing on the injured ankle joint and took non-steroidal anti-inflammatory drugs under medical guidance. There was a surgical incision infection case in the RIF group, which healed after 3 weeks following daily wound dressing and use of sensitive antibiotics.

Compared with RIF, ELIN offers advantages including minimally invasive procedures, faster fracture union, shorter time to device removal, a more aesthetically pleasing appearance of the wound, and high patient satisfaction in treating trimalleolar fractures. These advantages well embody the concept of enhanced recovery after surgery. In contrast to traditional intramedullary fixation, ELIN realized locking fixation, reducing the risk of nail backing out and even nail fracture; however, it is more difficult to remove the nail.